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G.  L.  PEABODV 


NEURALGIA 


THE  DISEASES  THAT  RESEMBLE   IT 


FRANCIS  E.  ANSTIE,  M.D.,  London 

FELLOW  OF  THE   ROYAL  COLLEGE   OF   PHYSICIANS;    HONORARY   FELLOW  OF   KING's   COLLEGE, 
LONDON;     SENIOR     ASSISTANT     PHYSICIAN     TO    WESTMINSTER     HOSPITAL;     LEC- 
TURER ON  MEDICINE  IN  WESTMINSTER  HOSPITAL  SCHOOL  ;  PHYSICIAN 
TO   THE   BELGRAVIA    HOSPITAL    FOR   CHILDREN 


NEW  YORK  AND  LONDON 

P.  PUTNAM'S    SONS 

ffil^e  ^nickrljotkEr  ^ttss 
1885 


Press  of 

G.  p.  Ptdnam's  Sons 

New  York 


PREFACE. 


I  BELIEVE  it  will  not  be  disputed  that  there  was  considerable 
need  for  an  English  treatise  dealing  rather  fully  with  the  sub- 
ject of  Neuralgia,  and  therefore  I  hope  that  the  profession  will 
be  willing  to  give  me  a  hearing.  The  present  work,  moreover, 
does  not  profess  to  be  a  mere  compilation  of  standard  authori- 
ties corrected  down  to  the  present  time,  but  puts  forward  a  sub- 
stantially new  view  of  the  subject — at  least,  a  view  that  has 
been  only  briefly  sketched  by  me  in  an  article  that  ajppeared, 
three  years  ago,  in  Reynolds's  "System  of  Medicme."  My 
principal  object,  in  writing  this  volume,  was  to  vindicate  for 
Neuralgia  that  distinct  and  independent  position  which  I  have 
long  been  convinced  it  really  holds,  and  to  prove  that  it  is  not 
a  mere  offshoot  of  the  Gouty  or  Rheumatic  diatheses,  still  less 
a  mere  chance  symptom  of  a  score  of  different  and  incongruous 
diseases.  In  order  to  set  the  diagnosis  of  true  Neuralgia  from 
its  counterfeits  in  the  clearest  light,  it  seemed  advisable  to  draw 
separate  pictures  of  each  of  the  latter  (at  least  of  as  many  as 
are  of  real  importance)  and  present  them  separately,  as  a  kind 
of  gallery  of  spurious  neuralgias,  and  this  I  have  done  iu  the 
second  part  of  the  volume.  No  one  who  had  not  tried  to  do  it 
would  imagine  how  difficult  this  latter  kind  of  work  is.  It  was 
necessary  for  the  sketches  to  be  very  brief  (unless  my  book  was 
to  become  umnanageably  large),  and  yet  to  be  as  truthfully 
characteristic  as  possible ;  and  it  was  necessary  also  that  only 
those  diseases  which  so  much  resemble  Neuralgia  as  practically 
to  lead  medical  men  astray  in  diagnosis,  should  be  dealt  with. 
The  selection  of  the  subjects,  and  the  execution  of  this  part, 
took  a  long  time,  though  it  only  covers  about  fifty  pages.  Then, 
as  regards  Neuralgia  itself,  it  became  necessary  to  completely 
recast  the  chapters  on  "  Pathology  "  and  on  "Complications," 
on  account  of  some  of  the  polite  criticisms  which  Dr.  Eulen- 
burg  directed  (in  his  recent  ' '  Lehrbuch  der  Nervenkrank- 

3 


4  PREFACE. 

heiten  ")  to  my  argument  in  the  article  above  referred,  to,  since 
it  was  obvious  tiiat  a  too  brief  statement  of  my  views  liad 
caused  them  to  be  partially  misunderstood  by  the  German  phy- 
sician. These  chai^ters  (Part  I.,  Chapters  II.  and  III.)  are 
certainly  the  most  important  portion  of  my  book,  and  I  would 
particularly  direct  attention  to  them,  in  order  that  their  con- 
tents may  be  affirmed  or  corrected :  the  reader  will  at  any  time 
find  that  they  contain  a  kind  of  investigation  never  before  sys- 
tematically carried  out  with  regai-d  to  Neuralgia.  The  causes 
above  mentioned,  together  with  others  over  which  I  had  no 
control,  have  kept  back  the  appearance  of  this  work  so  long 
beyond  the  date  for  which  it  was  originally  announced,  that  I 
feel  I  ought  to  apologize  for  an  amount  of  delay  that  would 
seem  hardly  justified  by  the  moderate  size  of  the  volume. 

16  WiMPOLE  Street,  London,  October  1,  1871. 


CONTENTS. 


INTEODUCTION— ON  PAIN  IN  GENEEAL      . 

PART   I. 

ON  NEURALGIA 

Chap.     I.— Clinical  History        .       .       . 
II. — Complications  of  Neuralgia    . 
III. — Pathology  and  Etiology  of  Neuralgia 
IV. — Diagnosis  and  Progress  of  Neuralgia 
V. — Treatment  op  Neuralgia  . 


PAGE 
12 

79 
9G 

349 


PART    II. 

DISEASES  THAT  RESEMBLE  NEURALGIA, 

Chap.      I.— Myalgia 136 

II. — Spinal  Irritation 200 

III. — The  Pains  of  Hypochondriasis        .        .    207 

IV. — The  Pains  of  Locomotor  Ataxy     ,        .210 

V. — The  Pains  of  Cerebral  Abscess     .        .213 

VI. — The  Pains  of  Alcoholism.        .        .        .    2L5 

VII. — The  Pains  of  Syphilis       .        .        .        .218 

VIII. — The   Pains   op   Subacute   and    Chronic 

Eheumatism 225 

IX. — The  Pains  op  Latent  Gout      .        .        .    227 
X. — Colic,  and   other  Pains  op  Peripheral 

Irritation 2i!9 

XI. — Dyspeptic  Headache Sl'l 

5 


II^TTEODUCTIOK 


ON  PAIN  IN  GENERAL. 

Although  it  is,  in  a  general  way,  unadvisable  to  introduce 
abstract  discussions  into  a  treatise  which  should  be  strictly 
practical,  it  is  almost  impossible  to  avoid  some  few  general 
reflections  on  the  physiological  import  of  Pain,  as  a  prelimi- 
nary to  the  discussion  of  the  maladies  which  form  the  subject 
of  this  volume.  This  whole  group  of  disorders  is  linked  to- 
gether by  the  fact  that  pain  is  their  most  prominent  feature ; 
and,  with  regard  to  most  of  them,  the  relief  of  the  pain  is  the 
one  thing  required  of  the  physician.  It  seems,  therefore,  very 
impoi'tant  that  we  should  ascertain,  at  least  approximately,  in 
what  the  immediate  state  consists,  which  consciousness  inter- 
prets as  pain.  It  is  not  necessary  to  enter  at  this  stage  into 
any  inquiry  as  to  the  pathological  causes  of  the  phenomenon ; 
what  we  know  of  these,  and  it  is  unfortunately  too  little,  will 
be  discussed  in  detail  under  the  l.eadings  of  the  several  affec- 
tions which  I  shall  have  to  describe. 

The  question  before  us  now  is  this  :  Wliat  is  that  functional 
state  of  the  nerves  which  consciousness  interprets  as  pain  ?  Is 
it,  or  is  it  not,  an  exaltation  of  the  ordinary  function  of  sensa- 
tion ? 

The  latter  question  is  generally  answered  affirmatively, 
without  much  thought,  by  those  to  whom  it  casually  occurs; 
but  indeed  there  is  plenty  of  prescriptive  authority  for  so  deal- 
ing with  it.  Pain  has  been  described  by  some  of  the  most  dis- 
tinguished writers  on  nervous  diseases  as  a  hypertesthesia. 
Yet  there  is  really  little  difficulty  in  convincing  ourselves,  if 
we  institute  a  thorough  inquiry  into  the  matter,  that  pain  is 
certainly  not  a  hypera^sthesia,  or  excess  of  ordinary  sensory 
function,  but  something  which,  if  not  the  exact  opposite  of 
this,  is  very  nearly  so. 

The  leading  fallacy  in  the  common  view  is  the  confusion 
which  is  perpetually  being  made  between  function  and  action. 
Now,  the  function  of  individual  nerves  is  very  nearly  a  con- 
stant qiiantity,  at  least,  it  varies  only  within  narrow  limits  ; 
while  the  action  of  the  same  nerves  may  be  almost  any  thing. 
The  function  of  the  nerve  is  that  kind  of  work  for  which  it  is 
fit  when  its  molecular  structure  is  healthy ;  it  is  the  series  of 

7 


8  INTRODUCTION. 

dynamic  reactions  which  are  necessarily  produced  in  nerve 
tissue  by  the  external  influences  which  surround  and  impinge 
upon  it  in  the  conditions  of  ordinary  existence.  The  action  of 
nerves,  under  the  pressui'e  of  extraordinary  influences,  may 
include  all  manner  of  vagaries  which  really  have  nothing  in 
common  with  the  elfects  of  ordinary  functional  stimulation; 
which  are,  in  fact,  nothuig  but  perturbation.  No  one  can 
suppose,  for  instance,  that  the  explosive  disturbances  of  nerve- 
force  which  give  rise  to  the  convulsions  of  tetanus  are  ;iny 
mere  exaggerated  degree  of  tlie  orderly  and  symmetrical  action 
by  which  the  healthy  nerve  responds  to  the  stimulus  of  volition 
ordering  a  given  set  of  muscles  to  contract;  they  ai'e  some- 
thing quite  diS'erent  in  kind.  And  so  it  is  with  the  sensory 
nerves.  The  functions  of  these  conductors,  in  health,  is  to 
convey  to  the  perceptive  centres  the  sensations,  varying  only 
within  a  most  limited  range,  which  correspond  to  a  state  of 
well-being  of  the  organs,  and  which  excite  only  tho;^  reflex 
actions  that  are  necessary  to  life.  Thus  the  large  surface  of 
sensitive  nerve  terminals  which  is  represented  by  the  collective 
peripheral  branches  of  the  Hfth  cranial  conveys  to  the  medulla 
oblongata  an  impression,  derived  from  the  temperature  and 
movement  of  the  surrounding  air,  when  the  latter  is  neither 
too  hot  nor  too  cold,  which  imparts  to  the  brain  a  perception 
of  comfortable  sensations,  and  excites  in  return  the  reflex 
action  of  breathing,  which  is  necessary  to  life.  But  the  im- 
pression produced  on  this  same  peripheral  expanse  of  nerve- 
branches  by  prolonged  exposure  to  cold  wind  may,  and  often 
does,  convey  to  the  centres  sensations  which  are  quite  diff'erent 
and  provokes  reflex  movements  which  are  altogether  abnormal. 
Pain  is  the  product  in  one  direction  ;  sneezing,  perhaps,  in  the 
other.  It  seems  al^surd  to  say  that  sneezing  is  any  part  of  the 
function  of  those  motor  nerves  whose  action  regulates  the  per- 
forma,nce  of  expiration.  And  it  appears  to  me  not  less  absurd 
to  say  that  pain  is  the  function  of  the  sensitive  fibres  of  the 
trigeminus.  But  the  best  way,  perhaps,  to  illustrate  the  loose- 
ness and  incorrectness  of  applying  the  term  "  hyperassthesia  " 
(implying  exalted  function)  to  the  state  of  sensitive  nerves 
when  suflr'ering  pain,  is  to  examine  the  condition  of  distinctive 
perception  in  the  very  same  parts  to  which  the  painful  nerves 
are  distributed.  It  will  invariably  be  found,  as  we  shall  have 
occasion  to  see  more  fully  proved  hereafter,  that,  in  parts 
which  are  acutely  painful,  a  marked  bluntness  of  the  tactile 
perceptions  can  be  detected.  The  tactile  perceptions  are,  no 
doubt,  conveyed  by  an  independent  set  of  fibres  from  tliose 
which  convey  the  sense  of  i^ain.*  Yet  it  is  surely  impossible 
to  believe  the  effect  of  the  same  influence,  in  functional  power 
can  be  different — much  more  than  it  can  be  exactly  opposite — 
in  the  two  cases . 

*  See,  ou  this  subject,  some  remarks,  in  my  work  ou  "Stimulants 


INTRODUCTION.  9 

If  pain  be  not  a  heightening  of  ordinary  sensation,  then  we 
seem  to  be  shut  up  to  tlie  idea  that  it  is  a  perversion  owing  to 
a  molecular  change  of  some  pai't  of  the  machinery  of  sensation 
which  fi'ustrates  function.  For  it  is  to  be  observed  that,  while 
the  sensations  conveyed  by  the  healthy  nerve  are  correct  in 
the  indications  which  they  att'ord  to  the  percipient  brain,  the 
indications  given  by  pain  are  vague  and  lui  trust  worthy,  and 
often  seriously  misleading.  Not  to  speak  of  the  nerves  of  spe- 
cial sense,  or  of  the  fibres  which  convey  the  sensations  of  mus- 
cular movement,  even  the  nerves  of  common  sensation  do  carry 
to  the  internal  perception,  in  health,  a  distinct  impression  of 
the  well-being  of  the  organs  to  which  they  are  distributed.  Mr. 
Bain  f  has  well  pointed  out  the  positive  character  of  this  feel- 
ing, which  is  so  often  incorrectly  referred  to  as  if  it  were  a 
mere  negation  of  feeling.  It  is  a  sensation  of  equable  and  dif- 
fused comfort,  if  I  may  be  allowed  to  use  the  expression,  which 
streams  in  from  all  parts  of  the  organism  ;  and  there  is  no 
possibility  of  comparing  it,  in  any  scale  of  less  or  more,  with 
the  sensation  of  pain;  for  the  latter  commonly  conveys  no 
correct  information  as  to  the  organ  from  which  it  proceeds,  or 
appears  to  proceed.  Especially  is  this  the  case  in  the  neural- 
gias, for  more  commonly  than  not  the  apparent  seat  of  the  pain 
is  widely  removed  from  the  actual  seat  of  the  mischief  which 
causes  it. 

If  we  inquire  a  little  further  into  the  circumstances  under 
which  various  kiiids  of  pain  occur,  we  gain  some  fi^esli  sugges- 
tions. Among  the  neuralgias,  those  are  the  most  acutely 
agonizing  which  occur  under  circumstances  of  impaired  nutri- 
tion incident  to  the  period  of  bodily  decay,  and  strong  reasons 
will  be  hereafter  adduced  for  the  belief  that  there  is  especial 
impairment  of  the  nutrition  of  the  central  end  of  the  painful 
nerves.  To  find  a  parallel  to  the  severity  of  this  kind  of  pains 
we  must  turn  to  the  case  of  organic  tumors,  which,  from  their 
position,  structure,  and  mode  of  growth,  necessarily  exercise 
continuous  and  severe  pressure  on  the  branches  or  the  trunk 
of  a  nei've ;  or  to  the  class  of  pains  which  attend  severe  cramp, 
or  tonic  contraction  of  muscles.  Now,  it  can  scarcely  be 
doubted  that  in  the  latter  instance  there  is  an  abnormally  rapid 
and  violent  destruction  of  tissue  going  on ;  at  the  very  least 
there  is  an  extraordinarily  violent  and  irregular  manifestation 
of  motor  force.     In  any  case  the  patent  fact  here  is  dynamic 


and  Narcotics,"  on  Sir  W.  Hamilton's  "Theory  of  the  Relations  of 
Perception  and  Common  Sensation." 

Avery  distinct  and  carefnl  statement  of  the  distinction  between 
pain  and  hvpertesthesia  will  be  found  in  a  prize  essay"  On  Neural- 
gia" by  M.  C.  Vanlair,  Jorir.  dcBruxelies,  torn,  xl,  xli.,  1865. 

f  "  Senses  and  Intellect." 


10  INTRODUCTION. 

perturbation  of  a  severe  kind;  and,  in  the  instance  of  organic 
tumors  exercising  steady  and  continuously  inci'easing  pressure 
on  nerves,  one  can  scarcely  doubt  that  a  similar  perturbation, 
less  intense  but  more  enduring,  is  necessarily  set  up.  That 
which  can  be  done  in  the  way  of  producing  severe  pain  by 
thes3  severe  affections  of  the  peripheral  portions  of  nerves,  or 
of  tissues  lying  outside  them,  we  might  a  priori  expect  would 
be  effected  by  slighter  but  continuous  changes  ni  the  nutrition 
of  the  more  important  portion  of  the  nerve  itself — its  central 
gray  nucleus.  One  would  say  that  a  pathological  process 
which  continuously  and  progressively  lowered  the  standard 
of  nutrition  here  must  interfere  from  hour  to  hour,  certainly 
fro.n  day  to  day,  with  that  regular  and  equable  distribution  of 
force  which  is  the  essence  of  unimpeded  function. 

Take,  again,  the  case  of  the  ver}-  seA^ere  ])ain  which  fre- 
quently attends  inflammation  of  the  pleura  and  of  the  ijerito- 
neum.  Whatever  theory  of  the  causation  of  these  pains  we 
may  adopt,  it  is  certain  that  one  most  important  eh^ment  in 
their  production  and  maintenance  is  the  continual  movement 
and  friction  of  the  affected  i^arts.  But  there  is  little  doubt  that 
the  moving  muscles  are  involved  in  the  inflammatory  process, 
as  Dr.  Inman  has  correcth'  observed.  It  would  seem  plain  that 
under  these  circumstances — an  inflamed  muscular  structure 
forced  to  perform  its  ordinary  contractions  as  well  as  it  can 
— -there  must  be  powerful  dynamic  iDerturbation  going  on. 

If  perturbation  of  nerve-function — a  disturbance  quite  differ- 
ent from  mere  exaltation  of  the  normal  development  of  nerve- 
force — be  the  essence  of  pain,  how  comes  it  that  pains  of  the 
severest  type  may  be  produced  by  changes  in  structures  which 
are  usually  described,  for  practical  purposes,  as  lymg  outside 
the  nervous  system  ?  We  must,  in  the  first  place,  remark  that 
the  externalitj''  of  any  bodily  tissue  to  the  nervous  system  is 
more  a]3parent  than  real.  Microscopic  researches  are  constantly 
revealing  nerve-fibres,  in  ever-increasing  profusion,  which  pen- 
etrate to  parts  seemingly  the  least  vitalized  in  the  organism. 
But,  in  any  case,  the  nerves  are  certainly  the  ultimate  channel 
of  communication  between  the  suffering  part  and  the  sentient 
centre.  It  seems,  therefore,  the  inevitable  conclusion  that  a 
dynamic  perturbation  going  on  in  the  non-nervous  tissue  is 
continued  along  the  nerves  themselves  :  and  that  the  severity 
of  the  pain  perceived  by  the  conscious  centres  is  propoi'tionate 
to  the  tumultuousness.  the  want  of  coordination,  and  the  waste 
with  which  force  is  being'  evolved  in  the  cramped  muscle,  or 
whatever  structure  it  may  be,  in  which  the  pain  takes  its  source. 

Not  to  pursue  these  topics  further,,  we  may  sum  up  the  con- 
siderations which  have  now  been  adduced,  in  the  following 
general  propositions,  which  will  tend  to  simplify  the  examina- 
tion of  the  various  painful  disorders  "which  we  are  about  to 
discuss  : 


INTRODUCTION.  11 

1.  Pain  is  not  a  true  liyperaesthesia ;  on  tlie  contrary,  it  in- 
volves a  lowering  of  true  function. 

2.  Pain  is  due  to  a  perturbation  of  nerve-force,  originating 
in  dynamic  disturbance  either  -within  or  without  the  nervous 
system. 

3.  The  susceptibility  to  this  perturbation  is  great_  in  propor- 
tion to  the  physical  imperfection  of  the  nervous  tissue,  until 
this  imperfection  reaches  to  the  extent  of  cutting  off  nervous 
communications  (paralysis). 


PAKT  I. 

OK     N'EURALGIA 


CHAPTEE  I. 

CLES'ICAL  HISTORY. 

Neuralgia  may  be  defined  as  a  disease  of  the  nervous  sys- 
tem, manifesting-  itself  by  pains  which,  in  the  great  majority 
of  cases,  are  unilateral,  and  Avhich  appear  to  follow  accurately 
the  course  of  particular  nerves,  and  ramify,  sometimes  into  a 
few,  sometimes  into  all,  the  terminal  branches  of  those  nerves. 
These  pains  are  usually  sudden  in  their  onset,  and  of  a  darting, 
stabbing,  boriDg,  or  burning  character;  they  are  at  first  unat- 
tended with  any  local  change,  or  any  general  febrile  excite- 
ment. They  are  always  markedly  inieimittent,  at  any  rate  at 
first;  the  intermissions  are  sometimes  regular,  and  sometimes 
irregular ;  the  attacks  connnonly  go  on  iiicreashig  in  severity 
on  each  successive  occasion.  The  intermissions  are  distin- 
guished by  complete,  or  almost  complete,  freedom  from  suffer- 
ing, and  in  recent  cases  the  patient  appears  to  be  quite  well  at 
these  times;  except  that,  for  some  shoi't  time  after  the 
attack,  the  j^arts  through  which  the  painful  nerves  ramify  re- 
main sore,  and  tender  to  the  touch.  In  old-standing  cases, 
however,  persistent  tenderness,  and  other  signs  of  local  mis- 
cliief,  are  apt  to  be  developed  in  the  tissues  around  the  peri- 
l^heral  twigs.  Severe  neuralgias  are  usually  complicated  with 
secondary  afTectious  of  other  nerves  which  are  intimately 
connected  with  those  that  are  the  oi-iginal  seat  of  pain ;  and 
in  this  way  congestions  of  blood  vessels,  hypersecretion  or 
arrested  secretion  from  glands,  inflammation  and  ulceration  of 
tissues,  etc. ,  are  sometimes  brought  about. 

The  above  is  a  general  description  of  neuralgia  which  will 
identif}'  the  disease  sufficiently  for  the  purpose  of  introducing 
it  tlie  attertion  of  the  reader.  We  must  now  proceed  to  give 
a  more  accurate  account  of  its 

Clinical  History  and  Symptoms. — Tliese  vary  so  greatly  in 
different  kinds  of  neuralgia  that  it  will  be  necessary  to  discuss 
the  greater  part  of  this  subject  under  the  headings  of  the  spe- 
cial varieties  of  the  disease.  There  aj*e  certain  common  features, 
liowcver,  in  all  true  neuralgias. 

12 


ON  NEURALGIA.  13 

I.  In  the  first  place,  it  is  universally  the  case  that  the  condi- 
tion of  the  patient,  at  the  time  of  the  first  attack,  is  one  of 
debility,  either  general  or  special.  I  make  this  assertion  with 
coniidence,  notwithstanding  that  Valleix,  and  some  other  very 
able  observers,  have  made  a  contrary  statement.  In  the  first 
place,  it  is  certainly  the  case  that  the  larger  half  of  the  total 
number  of  cases  of  neuralgia  which  come  under  my  care  are 
either  decidedly  angemic,  or  else  have  recently  undergone  some 
exhausting  illness  or  fatigue  ;  and  if  other  writers  have  failed 
to  see  so  many  neuralgic  patients  in  whom  these  conditions 
were  present,  it  must  certainly  be  because  they  have  limited 
the  application  of  the  term  ' '  neuralgia  "  within  bounds  which 
are  too  narrow  to  be  justified  by  any  logical  argument;  as 
will,  indeed,  be  shown  at  a  later  stage.  On  the  other  hand, 
although  a  considerab  e  number  of  neuralgic  patients  have  an 
externally  healthy  appearance,  as  indicated  by  a  ruddy  coni- 
plexion  and  a  fah  amount  of  muscular  developixient,  it  cannot 
be  admitted  that  these  appearances  exclude  the  possibility  of 
dability,  either  structional  or  functional,  of  the  nervous  system.. 
The  commonest  experience  might  teach  us  that,  so  far  from  the 
nervous  system  being  invariably  developed  with  a  correspond- 
ing completeness  and  inaintained  with  a  corresponding  vigor  to 
tliose  which  distinguish  the  muscular  system  and  the  organs 
of  vegetative  life,  there  is  often  a  very  striking  contrast  be- 
tween these  in  the  same  individual.  What  physician  is  there 
who  has  not  seen  epilejptic  patients,  in  whom  mental  habitude, 
a  low  cranial  development,  imperfect  cutaneous  sensibility, 
and  other  obvious  marks  of  deficient  innervation,  were  marked 
and  striking  features  at,  or  even  before,  tho  first  occurrence  of 
convulsive  symptoms,  while  the  body  "was  robust,  the  face  well 
colored,  and  the  muscular  power  up  to  or  beyond  the  average? 
Now,  it  will  invariably  be  found,  on  carefully  sifting  the  his- 
tory of  apparently  robust  neuralgic  ijatients,  that  they,  too, 
have  given  previous  indications  of  weakness  of  the  nervous 
system:  thus,  women,  who,  after  a  severe  confinement  at- 
tended with  great  loss  of  blood,  are  attached  with  claviis  hys- 
tericus or  with  mif/rame;  will  inform  us  that  whenever,  in 
earlier  life,  they  suffered  from  headache,  the  pain  was  on  the 
same  side  as  that  now  affected,  and  chiefly  or  altogether  con- 
fined to  the  site  of  the  present  neuralgia.  In  a  considerable 
number  of  cases,  also,  in  which  I  have  been  able  to  observe 
accurately  the  events  which  preceded  an  attack  of  neuralgia,  it 
has  been  found  that  the  skin  supplied  by  the  nerves  about  to  be- 
come painful  was  anaesthesic  to  a  remarkable  degree ;  and  it  is 
very  often  the  case  that  a  more  moderate  amount  of  blunted  sen- 
sation was  perceptil)le  in  these  parts  daring  the  intervals  between 
attacks  of  pain.  A  somewhat  delusive  appearance  of  general 
nervous  vigor  is  often  conveyed  to  the  observer  of  neuralgic 
patients,  by  reason  of  the  intellectual  and  emotional  character- 


14  ON  NEURALGIA. 

istics  of  the  latter.  Both  ideation  and  emotion  are,  indeed, 
very  often  quick  and  active  in  the  victims  of  neuralgia,  who 
in  this  respect  difrer  strikingly  from  the  majority  of  epileptics. 
But  this  mobility  of  the  higher  centres  of  the  nervous  system 
is  itself  no  sign  of  general  nervous  strength  ;  which  last  can 
never  be  f)ossessed  except  by  those  in  whom  a  certain  balance 
of  the  various  nervous  functions  is  maintained.  Much  more 
will  be  said  on  this  topic  when  we  come  to  discuss  the  etiology 
of  neuralgia.  .  Meantime  I  may  content  myself  with  repeating 
the  fact  which  is  indubitably  taught  by  careful  observation — ■ 
that  neuralgics  are  invariably  marked  by  some  original  weak- 
ness of  the  nervous  system ;  though  in  some  cases  this  defect 
is  confined  strictly  to  that  part  of  the  sensory  system  which 
ultimately  becomes  the  seat  of  neuralgic  pain. 

Another  circumstance  is  common  to  all  neuralgias  of  super- 
ficial nerves ;  and,  as  a  large  majority  of  all  neuralgias  are 
superficial  in  situation,  this  is,  for  practical  purposes,  a  gen- 
eral characteristic  of  the  disease.  I  refer  to  the  gradual  for- 
m.ation  of  tender  spots  at  various  points  where  the  affected 
nerves  pass  from  a  deeper  to  a  more  superficial  level,  and  par- 
ticularly where  they  emerge  from  bony  canals,  or  pierce  fi- 
brous fascise.  So  general  is  this  characteristic  of  inveterate 
neuralgias,  that  Valleix  founded  his  diagnosis  of  the  genuine 
neuralgias  on  the  presence  of  these  painful  pomts.  Herein  he 
appeal's  to  me  to  be  decidedly  in  error.  I  have  watched  a  great 
many  cases  (of  all  sorts  of  varieties  as  to  the  situation  of  the 
pain),  and  I  have  uniformly  observed  that  in  the  early  stages 
firm  x^ressure  may  be  made  on  the  x)ainful  nerve  without  any 
aggravation  of  the  pain ;  indeed,  very  often  with  the  effect  of 
assuaging  it.  The  formation  of  tender  spots  is  a  subsequent 
affair :  they  develop)  in  those  situations  which  have  been  the 
foci,  or  severest  points,  of  the  neuralgic  pain.  There  is  how- 
ever, a  point  which,  though  not  always,  nor  often,  the  seat  of 
spontaneous  pain,  is  nevertheless  very  genei^ally  tender. 
Trousseau,  who  criticises  unfavorably  the  statement  of  Valleix 
as  to  the  situation  of  the  points  douleureux,  insists  that  this 
tender  spot,  which  is  over  the  spinous  processes  of  the  vertebrae 
corresponding  to  the  origin  of  the  painful  nerve,  and  which  he 
calls  the  points  apophysaire,  is  more  universally  present  than 
any  of  those  pointed  out  by  Valleix.  I  shall  hereafter  endeavor 
to  show  that  these  spinal  pomts  are  by  no  means  chai-acteristic 
of  neuralgia ;  they  are  present  in  a  variety  of  affections  which 
were  ably  described,  under  the  heading  of  "Spinal  Irritation," 
many  years  ago,  by  the  brothers  Grhfin  .  ["  Observations  on 
the  Functional  Affections  of  the  Spinal  Cord,"  by  William 
and  Daniel  Grilfiin.  London,  1834]  and  they  are  also  present 
with  misleading  frequency  in  cases  of  mere  myalgia, such  as 
I  shall  have  to  describe  at  a  later  stage. 

Another  characteristic  of  neuralgic  patients  in  general  is,  I 


ON  NEURALGIA.  J  5 

believe,  a  certain  mobility  of  the  vaso-motor  nervous  system 
and  of  the  cardiac  motor  nerves ;  but  I  insist  less  on  this  than 
on  the  above-named  features,  because  a  more  extended  experi- 
ence is  necessary  to  establish  the  fact  with  certainty.  Within 
my  own  experience  it  has  always  seemed  to  be  the  case  that 
persons  who  are  liable  to  neuralgia  are  specially  prone  to  sud- 
den changes  of  vascular  tension,  under  emotional  and  other 
influences  which  operate  strongly  on  the  nervous  system. 
The  observation  of  this  fact  has  been  made  accidentally,  with- 
out any  previous  bias  on  my  part,  in  the  course  of  a  large 
number  of  experiments  made  upon  individuals  free  from  man- 
ifest disease  at  the  time,  with  Marey's  sphygmograph. 

Neuralgic  attacks  are  always  intermittent,  or  at  the  least 
remittent,  in  every  stage  of  the  disease. 

The  manner  in  which  neviralgic  pain  commences  is  charac- 
teristic and  important.  There  is  always  a  degree  of  sudden- 
ness in  its  outset.  When  produced  by  a  violent  shock,  it  may, 
and  often  does,  spring  into  full  development  and  seveinty  at 
once,  of  which,  perhaps,  the  most  striking  example  is  the  sud- 
den and  violent  neuralgic  pain  of  the  eyebrow  which  some  per- 
sons experience  from  swallowing  a  lump  of  undissolved  ice 
Usually,  however,  the  first  warning  is  a  sudden,  not  very 
severe,  and  altogether  transient  dart  of  pain.  The  patient  has 
probably  been  suft'ering  from  some  degree  of  general  fatigue 
and  malaise,  and  the  skin  of  the  affected  part  has  been  some- 
what numb,  when  a  sudden  slight  stitch  of  pam  darts  into  the 
nerve  at  some  point  which  corresponds  to  one  of  the  foci  here- 
after to  be  particularized.  It  ceases  immediately,  but  in  a  few 
seconds  or  minutes  returns ;  and  these  darts  of  iDain  recur  more 
and  more  frequently,  till  at  last  they  blend  themselves  together 
in  such  a  manner  that  the  patient  suffei's  continuous  and  vio- 
lent j)ain  for  a  minute  or  so,  then  experiences  a  short  intermis- 
sion, and  then  the  pain  returns  again,  and  so  on.  These  inter- 
mittent spasms  of  pain  go  on  recui'ring  for  one  or  several 
hours ;  then  the  intermissions  become  longer,  the  pain  slighter, 
and  at  last  the  attack  wears  itself  out.  Such  is  generally  the 
history  of  first  attacks,  especially  in  subjects  who  a,re  not  past 
the  midtUe  age,  nor  particularly  debilitated  from  any  special 
cause. 

A  point  of  interest  in  connection  with  the  natural  history  of 
the  neuralgic  access  is  the  condition  of  the  circulation.  The 
commencement  of  pain  is  generally  preceded  by  paleness  of 
skin  and  sensations  of  chiHiness.  At  the  commencement  of 
the  painful  paroxysm,  sphygmographic  observation  shows 
that  the  arterial  tension  is  much  increased,  owing,  in  all  prob- 
ability, to  spasm  of  the  small  vessels.  This  condition  is  grad- 
ually replaced  by  an  opposite  state,  the  pulse  becoming  large, 
soft,  and  bounding,  though  very  unresisting,  and  giving  a 
sphygmographic  trace  which  exhibits  marked  dicrotism.     Sim- 


16  ON  NEURALGIA. 

ultaneously  with  this  the  skin  becomes  warmer,  sometimes 
even  uncomfortably  warm,  and  there  is  frequently  considera- 
ble flushing  of  the  face. 

Tiie  final  characteristic  common  to  all  neuralgias  is  that  fa- 
tigue, and  every  other  depressing  influence,  directly  predisi)ose 
to  an  attack,  and  aggravate  it  when  ali-eady  existing. 

Varieties.~li  is  possible  to  classify  neuralgias  upon  either  of 
two  systems:  first  (a),  according  to  the  constitutional  state  of 
the  patient;  and,  secoadl}^  (6),  according  to  the  situation  of  the 
affected  nerves.  It  will  be  necessary  to  follow  both  these  lines 
of  classification,  avoiding  all  needless  repetition. 

(a)  In  considering  tlie  influence  of  constitutional  states  upon 
the  typical  d3velopm3nt  of  neuralgia,  it  will  be  convenient  to 
commence  Vvrith  the  group  of  cases  in  which  the  general  condi- 
tion of  the  organisai  produces  the  least  effect.  This  is  the  case 
when  the  pain  is  tlie  result  of  direct  injury  to  a  nerv^e-trunk, 
whether  by  external  violence,  by  the  mechanical  pressure  of  a 
tumor,  or  by  the  involvement  of  a  nerve  in  inflammatory  or 
ulcerative  processes  originating  in  a  nsighboriug  part.  A.s  re- 
gards the  development  of  symptoms,  the  important  matters  are, 
that  the  pain  in  tiiese  cases  commences  comparatively  gradualh^, 
that  the  intermissions  are  usually  more  or  less  comjilete,  and 
that  the  pain  is  far  less  amenable  to  relief  from  remedies,  than 
in  other  forms  of  neuralgia.  The  little  that  can  be  said  about 
the  form  which  is  dependent  upon  progressively  inci'easing 
pressure,  or  involvement  of  a  nerve  in  malignant  ulcerations, 
caries  of  bones  or  teeth,  etc.,  falls  under  the  heads  of  Diagnosis 
and  Treatment,  and  need  not  detain  us  here.  Tne  clinical  his- 
tory of  neuralgia  from  external  violence,  however,  re|uires 
separate  discussion : 

1.  Neuralgia  from  external  shock  jnay  be  pi'oducel  by  a 
physical  cause  (as  by  a  fall,  a  railwa}^  collision,  etc.),  which 
gives  a  jar  to  the  central  nervous  system;  or  by  severe  mental 
emotion,  operating  upon  the  same  part  of  the  oi'ganism. 
Under  either  of  these  circumstances  the  development  of  the 
affection  may  occur  at  once,  but  by  far  the  most  frequently  it 
ensues  after  a  variable  interval,  during  which  the  patient 
shows  sig'ns  of  general  depression,  with  loss  of  appetite  and 
sti'ength.  Sometimes  voaiiting,  and  in  other  instances  paral- 
ysis, of  a  partial  and  temporary  kind,  occui'.  When  once  de- 
veloped, the  neuralgic  attacks  do  not  differ  from  those  which 
proceed  from  causes  internal  to  the  organism.  In  the  greater 
number  of  instances,  so  far  as  ni}^  experience  goes,  it  is  the 
fifth  cranial  nerve  which  becomes  neuralgic  from  the  effects  of 
central  shock.  Illustrative  cases  v.dll  be  given  in  the  section 
on  Local  Classification.  Meantime  the  important  facts  to  note, 
in  relation  to  the  influence  of  constitutional  states,  are  these: 
In  the  first  place,  the  tendency  of  such  accidents  to  excite 
neuralgia  varies   directly  with  the  hereditary  predisposition 


ON  NEURALGIA.  17 

evinced  by  the  liability  of  the  sufferer's  family  to  neuralgic  af- 
fections and  to  the  more  serious  neuroses.  Secondly,  the 
likeliliood  of  a  neuralgic  attack  is  indeiinitely  increased  if  he 
has  ah-eady  had  neuralgia.  Thirdly,  although  debility  from 
temporary  and  special  causes  can  rarely  be  sufficient  to  insure 
a  true  neuralgic  access  after  a  severe  shock,  it  probably  height- 
ens, indefinitely,  the  tendency  in  a  person  otherwise  predis- 
p»osed.  Delicate  women  are  many  times  more  liable  to 
experience  such  consequences,  froin  a  physical  or  mental 
shock,  than  men  of  tolerably  robust  constitution. 

2.  Neuralgia  fi^om  direct  violence  to  superficial  nerves  is 
produced  by  cutting  or,  more  rarely,  by  bruising  wounds. 
Cutting  wounds  may  divide  a  nerve-trunk  (a)  partially,  or  (6) 
completely. 

(a)  When  a  nerve-trunk  is  partially  cut  through,  neuralgic 
pain  occurs,  if  at  all,  immediately,  or  almost  immediately,  on 
the  receipt  of  the  injury.  One  such  instance  only  has  come 
under  my  own  care,  but  many  others  are  recorded.  In  my 
case  the  ulnar  nerve  was  partly  cut  through,  with  a  tolerably 
sharp  bread-knife,  not  far  above  the  wrist;  partial  an^p.sthesia 
of  the  little  and  ring  fingers  was  induced,  but  at  the  same  time 
violent  neuralgic  pains  in  the  little  finger  came  on,  in  fits  re- 
curring several  times  a  day,  and  lasting  about  half  a  minute. 
Treatment  was  of  little  a])parent  effect  in  promoting  a  cure; 
though  opiates  and  the  local  use  of  cliloroform  afforded  tem- 
porary relief.  The  attacks  recuri'ed  for  moi'e  than  a  month, 
long  after  the  original  wound  had  healed  soundly;  and,  for  a 
long  time  after  this,  pressure  on  the  cicatrix  would  reproduce 
the  attacks.  A  slight  amount  of  anaesthesia  still  remained, 
when  I  saw  the  patient  more  than  a  year  after  the  injury. 

(6)  Complete  severance  of  a  nerve-trunk  is  a  sufficiently 
comimon  accident,  far  more  common  then  is  neuralgia  ]>ro- 
duced  by  such  a  cause;  iaideed,  so  marked  is  this  disproportion 
between  the  injury  and  the  special  result,  that  I  have  been  led 
to  infer  that  a  necessary  factor  in  the  chain  of  morbid  events 
must  be  the  existence  of  some  antecedent  peculiarity  in  the 
central  origin  of  the  injured  nerve.  This  opinion  is  rendei^ed 
the  more  probable  because  the  consecutive  neuralgia  is  in  some 
cases  situated,  not  in  the  injured  nerve  itself,  but  in  some  other 
nerve  with  which  it  has  central  connections.  Two  such  cases 
are  recorded  in  my  Lettsomian  Lectures,  [Lancet,  186G],  in 
which  the  ulnar  nerve,  and  one  in  which  the  cervico-occipital, 
were  com])letely  divided;  in  all  three  the  resulting  neuralgia 
was  developed  in  the  braiiches  of  the  fifth  cranial.  Here  we 
may  suppose  that  the  weak  point  existed  in  the  central  nucleus 
of  the  fifth;  and  that  the  irritation,  or  leather  dej>ression,  com- 
municated to  the  whole  spinal  centres  by  the  wound  of  a  dis- 
tant nerve,  first  found,  on  reaching  this  weak  point,  the  neces- 
sary conditions  for  the  develoiraient  of  the  neuralgic  form  of 


18  ON  NEURALGIA. 

pain,  which  therefcre  would  be  represented  to  the  mental  per- 
ception as  present  in  the  peripheral  branches  of  the  fifth  nerve. 
In  all  the  cases  which  have  come  under  my  notice,  the  neu- 
ralgia set  in  at  a  particular  period,  namely,  after  complete 
cicatrization  of  the  wound,  and  while  the  functions  of  the 
branches  on  the  peripheral  side  of  the  wound  were  partly,  but 
not  completely,  restored.  The  same  obstinacy  and  rebellious- 
ness to  treatment  are  observed  as  in  other  instances  of  neural- 
gia from  injury. 

One  of  the  cases  above  referred  to  may  here  be  briefly  de- 
tailed, as  it  shows  very  completely  the  clinical  history  of  such 
affections.  C.  B.,  aged  twenty-four,  an  agricultui-al  laborer, 
applied  for  relief  in  the  out-patient  room  of  Westminster 
Hospital,  suffering  from  severe  neuralgic  pains  of  the  forehead 
and  face  of  the  left  side.  Then  pains  were  felt  in  the  course  of 
the  supra-orbital,  ocular,  nasal,  and  supra-trochlear  branches, 
and  also  in  the  cheek,  appearing,  there,  to  radiate  from  the  in- 
fra-orbital foramen.  They  had  commenced  about  three  weeks 
previously  to  the  patient's  first  visit  to  the  hospital,  and  about 
six  weeks  after  the  accident  which  appeared  to  have  started  the 
whole  train  of  symptoms.  This  was  a  cutting  wound,,  evi- 
dently of  considerable  depth  as  well  as  external  size,  towai'd 
the  back  of  the  neck,  and  so  situated  that  it  must  have  divided 
the  great  occipital  nerve  of  the  left  side :  and,  from  the  man's 
account  of  the  numbness  of  the  parts  supplied  by  the  nerve 
which  immediately  followed  the  wound,  there  could  be  no 
doubt  that  this  had  occurred.  There  was  no  acute  nerve-pain, 
either  during  the  healing  of  the  wound,  which  was  rapid,  or 
subsequently,  until  more  than  three  weeks  from  the  date  of  the 
injury;  at  this  time  there  was  still  a  considerable  sense  of 
numbness  m  the  skin  of  the  occipital  and  upper  cervical  region ; 
but  there  now  commenced  a  series  of  short  paroxj'sms  of  pain 
in  the  forehead  of  the  same  side.  These  at  first  occurred  only 
about  twice  daily,  at  regular  intervals ;  the  pain  was  not  very 
sharp,  and  only  lasted  a  minute  or  tv/o.  The  attacks  rapidly 
increased  in  frequency  and  duration,  however,  and  extended 
their  area.  At  the  time  when  I  first  saw  the  case  the  pain  was 
very  formidable,  it  recurred  with  great  frequency  during  the 
day,  but  would  sometimes  leave  tlae  patient  free  for  several 
hours  together.  The  site  of  the  wound  was  occupied  by  a  firm 
cicatrix  of  about  a  line  in  breadth  and  an  inch  and  a  quarter 
in  length ;  pressure  on  this  excited  only  a  vague  and  slightly 
painful  tingling  in  the  part  itself,  but  severely  aggravated  the 
trigeminal  pains,  or  reproduced  them  if  they  happened  to  be 
absent.  The  regions  supplied  by  the  great  occipital  nerve  were 
still  very  imperfectly  sensitive.  This  patient  gave  me  a  great 
deal  of  trouble.  He  continued  for  many  weeks  under  my  care, 
and  I  can  scarcely  flatter  myself  that  any  of  the  numerous 
rencedies  which  I  administered  internally,  or  applied  locally, 


ON   NEURALGIA..  19 

had  any  serious  effect  in  checking  the  disorder.  The  subcu- 
taneous injection  of  morphia  gave  some  rehef,  as  it  always 
does,  but  this  seemed  to  be  perfectly  transitory ;  and,  although 
•when  the  patient  ceased  to  attend  the  hospital  he  was  decidedly 
better,  I  cannot  imagine  that  there  was  anything  in  it  except 
the  slow  wearing  out  of  the  neuralgic  tendency,  very  much 
without  reference  to  the  administration  of  any  remedies. 

Tlie  description  of  neuralgia  from  injury  would  be  incom- 
plete without  some  special  words  on  a  variety  of  this  affection 
which  has  only  very  recently  been  described  with  that  fulness 
which  it  deserves.  I  refer  to  the  pains  which  are  produced  by 
gunshot  injuries  of  nerves,  received  in  battle,  of  which  no  suf- 
ficient account  had  been  given  until  the  publication  of  the  ex- 
perience of  Messrs.  Mitchell,  Moorehouse,  and  Keen,  in  the 
late  American  civil  war.* 

From  the  Interesting  treatise  of  the  above-named  writers  it 
appears  that  not  merely  is  neuralgia  of  an  ordinary  type  a  fre- 
quent after-consequence  of  wounds,  but  that  certain  special 
pains  are  not  unfrequently  produced.  In  the  more  ordinary 
instances,  pain  is  of  the  darting,  or  of  the  aching  kind ;  and 
all  writers  on  military  surgery,  who  have  recorded  their  expe- 
rience of  the  results  of  wounds  received  in  battle,  have  spoken 
of  affections  of  this  kind,  for  the  most  part  singularly  severe 
and  obstinate,  and  in  not  a  few  recorded  instances  clinging  to 
the  patient  during  the  remainder  of  his  life.  These  pains  may 
at  times  leave  the  sufferer,  but  they  infallibly  recur  when  from 
any  cause  his  health  is  depressed,  and  it  is  an  especially  com- 
mon thing  for  them  to  be  evoked  in  full  severit}^  under  tne  in- 
fluence of  exposure  to  cold,  and  x^articularly  to  damp  cold. 

But  the  American  writers  introduce  us  to  another  and  more 
terrible  neuralgia  which  is  a,  fortunately,  less  frequent  result 
of  serious  injuries  to  nerves.  They  speak  of  it  as  a  burning 
pain  of  intense  and  often  intolerable  severity ;  they  believe  that 
it  seldom  if  ever  originates  at  the  moment  of  the  injury,  but 
rather  at  some  time  during  the  healing  process ;  and  it  is  espe- 
cially noteworthy  that  it  is  sometimes  felt  not  in  the  nerve  ac- 
tually wounded,  but  in  some  other  nerve  with  which  it  has 
connections.  After  is  has  lasted  a  certain  time,  an  exquisite 
tenderness  of  the  skin  is  developed,  and  a  peculiar  physical 
change  of  skin-tissure  occurs;  it  becomes  thin,  smooth,  and 
glossy.  It  is  a  remarkable  fact  that  these  burning  pains  which 
are  so  definitely  linked  with  a  nutrition-change  of  skin  are 
never  felt  in  the  trunk,  and  rarely  in  the  arm  or  thigh,  not 
often  in  the  forearm  or  leg,  but  commonly  in  the  foot  or  hand; 
and  the  nutrition  changes  of  the  skin  are  generally  observed 
on  the  palm  of  the  hand,  the  palmar  surface  of  the  fingers,  or 

*  "  Gunshot  Wounds  and  odier  Injuries  to  Nerves."  Pliiladel- 
phja:    Lippincott  &  Co.,  1864 


20  ON  NEURALGIA. 

the  dorsum  of  the  foot ;  rarely  on  the  sole  of  the  foot  or  the 
back  of  the  hand.  It  is  very  interesting  to  remark  that  these 
skin-lesions  correspond  very  nearly,  not  only  to  those  ohserved 
in  the  cases  of  nerve-injury  reported  by  Mr.  Paget,*  in  which 
actual  neuralgia  was  i^resent  (though  the  kind  of  pain  is  not 
exactly  specified),  bvxt  also  very  nearly  with  the  nutritive 
changes  observed  by  Mr.  Jonathan  Hutchinson  in  a  number 
of  cases  of  surgical  injuries  of  nerve*t  The  tendency  of  neu- 
ralgic pain  accompanied  by  nutritive  lesions  of  the  skin  and 
nails  to  seat  itself  in  the  hands  and  feet  will  be  hereafter  noted 
in  connection  with  the  subject  of  the  pains  of  locomotor  ataxy 
and  of  those  produced  by  profound  mercurial  x)oisoning.  And 
it  will  be  seen  in  the  section  on  Pathology,  that  very  import- 
ant conclusions  are  suggested  by  the  coincidence., 

Joined  with  the  burning  pains,  and  the  altered  skin-nutri- 
tion, in  the  cases  of  gunshot  injury  of  nerves  which  we  are 
considering,  there  is  nearly  always  a  marked  alteration  in  the 
temperature  of  the  parts,  either  in  one  direction  or  the  other. 
In  the  great  majority  of  instances  of  ordinary  neuralgia  after 
Vfounds,  this  alteration  is  a  very  considerable  reduction  of  the 
temperatui^e  of  the  parts  supplied  by  tlie  painful  nerves;  a 
change  which  corresponds  with  what  appears  in  the  vast  ma- 
jority of  all  cases  of  division  of  sensitive  nerves,  whether  pain 
be  set  up  or  not.  But,  in  all  examples  of  the  burning  pain  af- 
ter injury,  Messrs.  Mitchell,  Moorehouse,  and  Keen  found  the 
temperature  of  the  painful  parts  notably  elevated. 

It  would  appear  that  there  is  no  form  of  neuralgia  more 
dreadful,  and  scarcely  any  so  hopeless,  as  this  burning  pain 
coming  on  as  a  sequel  to  severe  nerve  injuries.  It  exercises  a 
profoundly  depressing  effect  upon  the  whole  nervous  tone;  the 
most  robust  men  become  timid  ai:id  broken  down,  and  their 
condition  is  compared  by  the  American  writers  to  that  of  hys- 
terical women. 

There  is  another  peculiar  nutritive  affection,  first  recognized 
as  an  occasional  consequence  of  nerve  injuries  by  Messrs. 
Mitchell,  Moorehouse,  and  Keen,  namely,  an  inflammation  of 
joints,  and,  although  we  have  no  concern  here  with  this  symp- 
tom, it  wall  be  referred  to  hereafter  as  throwing  interesting 
light  on  certain  questions  of  pathology.  Certain  lesions  of  se- 
cretion will  also  be  specially  referred  to  under  the  heading  of 
Diagnosis. 

It.  Neuralgias  op  Intra-nervous  Origin. — As  regards  the 
constitutional  conditions  with  which  the  several  varieties  of 
neuralgia  that  arise  independently  of  external  violence,  or  dis- 
ease of  extra-nervous  tissues,  are  respectively  allied,  the  follow- 
ing preliminaiy  subdivisions  may  be  made: 

*  lied   Times  and  Gazette,  ]Marcli  2G,  18G4.    - 
f  "  London  IIosp.  Reports,"  1866. 


ON  NEURALGIA.  21 

1.  Neuralgias  of  malarious  origin. 

2.  Neuralgias  of  the  period  of  bodily  development. 

3.  Neuralgias  of  the  middle  period  of  life. 

4.  Neuralgias  of  the  period  of  bodily  decay. 

5.  Neuralgias  associated  with  anasmia  and  mal-nutrition. 

1.  Neuralgias  of  malarious  origin  were  formerly  far  more 
prevalent  than  they  are  at  present,  within  the  sphere  of  the 
English  practitioner  of  medicine;  with  the  genei^al  decline  of 
malarial  fevers,  consequent  on  imiDroved  drainage  and  cultiva- 
tion of  lands,  they  have  become  constantly  more  scarce.  The 
districts  in  which  they  still  are  found  to  prevail  with  any  fre- 
quency are  carefully  speciiied  in  the  interesting  report  of  Dr. 
Whitley  to  the  Medical  Officer  of  the  Privy  Council,  in  the 
Blue-Book  for  1863. 

Of  course,  however,  there  are  a  considerable  number  of  per- 
sons continually  returning  to  England  from  countries  where 
malarious  diseases  are  common ;  and  these  often  bear  about 
with  them  the  effects  of  paludal  poisoning  which  occasionally 
exhibits  itself  in  the  form  of  neuralgia.  Till  very  lately,  how- 
ever, I  had  not  happened  to  come  across  such  cases,  although 
at  one  time  and  another  I  have  seen  and  treated  a  good  many 
persons  returned  from  India  and  Africa,  whence  I  judge  that 
neuralgia  with  this  special  history  is  less  common  than  many 
seem  to  think.  In  former  times,  on  the  contrary,  malarioid 
neuralgias  were  so  connnon  that  they  forced  themselves  on  the' 
notice  of  every  practitioner.  The  term  "brow-ague,"  to  this 
day  applied  by  many  medical  men  to  every  variety  of  supra- 
orbital neuralgia,  is  a  relic  of  the  older  experience  on  this 
point,  as  is  also  the  very  common  mistake  of  expecting  all  neu- 
ralgic affections  to  present  a  distinctly  rhythmic  recurrence  of 
symptoms. 

In  the  year  1864  I  published  the  statement  *  that,  "  in  a  fair 
sprinkling"  of  the  cases  of  neuralgia  which  present  themselves 
in  hospital  out-patient  rooms,  ague-poisoning  may  be  suspected ; 
but  I  was  then  speaking  rather  from  hearsay  than  from  my 
own  experience,  which,  in  fact,  had  yielded  no  clear  cases  of 
this  sort  of  neuralgia,  and  was  till  just  recently  unable  to 
reckon  iip  more  than  two  undoubted  and  one  doubtful  case  of 
the  affection,  in  all  of  which  the  fifth  cranial  nerve  was  unat- 
tacked.  The  periodicity  in  one  of  the  genuine  cases  was  reg- 
ular tertian,  in  the  other  regular  quotidian.  A  semi-algide 
condition  always  ushered  in  the  attacks;  but  this  was  gradu- 
ally exchanged,  as  the  pain  continued,  for  a  condition  in  which 
the  pulse  was  rapid  and  locomotive,  but  compressible,  and  the 
strength  was  further  depressed.  In  both  these  cases  there  was 
unilateral  flushing  of  the  face,  and  congestion  of  the  conjunc- 
tiva, to  a  slight  degree,  during  the  attack  of  pain.     The  pain 

*  "  Stimulants  and  Narcotics,"  Macmillan,  1854,  p.  86. 


22  ON  NEURALGIA. 

became  duller  and  moi'e  diffused  contemporaneously  with  the 
lowering'  of  arterial  pressure ;  and,  after  the  disappearance  of 
active  pain,  moderate  tenderness  over  a  considerable  tract 
round  the  course  of  the  painful  nerves  remain  for  some  time. 
There  was  no  distnact  development  of  painful  points  in  the  situ- 
ations described  by  Valleix ;  but  it  should  be  reixiarked  that  tlie 
cases  were  rapidly  cured  with  quinine,  which  very  probably  ac- 
counts for  this  circumstance. 

Till  lately  I  had  not  witnessed  neuralgia  as  an  after-conse- 
quence of  tropical  malaiua-poisoning,  although  I  have  had 
many  cases  of  other  diseases,  the  relics  of  hot  climates,  under 
my  care  ;  but  within  the  last  year  I  have  seen  a  case  of  ex- 
tremely severe  intercostal  neuralgia  of  a  perfectly  periodic  type 
occurring  in  a  patient  whose  constitution  had  beeri  thoroughly 
saturated  with  tropical  marsh  poison,  and  in  whom  the  spleen 
was  still  much  enlai'ged.  The  neuralgia  was  so  terrible,  and 
accompanied  by  such  severe  algide  phenomena  at  the  begin- 
ning of  the  attacks,  and  such  a  sense  of  throbbing  as  the  i^ain 
developed,  as  to  lead  to  serious  suspicions  of  hepatic  abscess, 
for  the  moment ;  but  the  course  of  events  soon  corrected  this 
idea. 

2.  Neuralgias  of  the  Period  of  Bodily  Development. — "Bj 
the  "period  of  bodily  development"  is  here  understood  tlie 
whole  time  from  birth  up  to  the  twenty-fifth  year,  or  there- 
abouts. This  is  the  period  during  which  the  organs  of  vegeta- 
tive and  of  the  lower  animal  life  are  growing  and  consolida- 
ting. The  central  nervous  system  is  more  slow  in  reaching  its 
fullest  development,  and  the  brain  especially  is  many  years 
later  in  acquiring  its  maximum  of  organic  consistency  and 
functional  power. 

That  portion  of  the  period  of  development  which  precedes 
puberty  is  comparatively  free  from  neuralgic  affections.  At 
any  i-ate,  it  is  rare  to  meet  in  young  children  with  well-defined 
unilatei'al  neuralgia,  except  from  some  very  special  cause,  such 
as  the  pressure  of  tumors,  etc.  Such  neuralgias  as  do  occur 
are  commonly  bilateral,  and  are  connected  either  with  the  fifth 
cranial  or  the  occipital  nerves. 

I  must  here  mention  an  affection  which  was  quite  unknown 
to  my  experience,  but  was  brought  under  my  notice  by  the 
late  Dr.  Hillier,  who  kindly  called  my  attention  to  tlie  notes 
of  two  cases  which  were  published  in  his  interesting  work  on 
"Diseases  of  Children."  The  cases  are  those  of  two  female 
children,  aged  nine  and  eleven  respectively,  in  whom  the 
principal  symptom  was  violent  and  paroxysmal  neuralgic 
headache.  In  both  of  these  children  the  existence  of  cerebral 
tubercle  was  suspected,  but  this  proved  to  be  a  mistake.  In 
both  thei'e  were  intolerance  of  light,  vomiting,  tonic  contrac- 
tion of  the  muscles  of  the  neck,  and  occasional  double  vision ; 
but  no  impairment  of  intelligence,  no  amaurosis,  and  no  para- 


ON  NEURALGIA.  23 

lysis  or  rigidity  of  the  limbs.  Each  of  these  children  died 
rather  suddenly,  after  a  violent  paroxysm  of  pain.  The  main, 
indeed  almost  the  only  characteristic  i^ost-mortem  change  was 
a  marked  loss  of  consistence  of  tissue,  in  one  case  in  the  pons 
varolii,  in  the  other  in  the  jpons,  the  medulla  oblongata,  and 
the  cerebellum .  These  cases  are  of  the  highest  possible  interest, 
as  are  also  several  other  instances  of  headache  iii  childi'en  re- 
corded by  Dr.  Hillier ;  notably  one  in  which  severe  paroxysmal 
pains  were  attended  with  general  impairment  of  brain-i^ower, 
and,  on  the  occurrence  of  death  from  exhaustion,  the  autopsy 
reveated  an  amount  of  degeneration  in  the  cerebral  arteries  (as 
also  in  the  general  arterial  system)  which  was  astonishing, 
considering  that  the  child  was  only  ten  and  a  half  years  old. 
This  case,  the  full  significance  and  interest  of  which  will  be 
better  seen  when  we  come  to  discuss  the  subject  of  pathology, 
is  an  example  of  physical  changes  in  the  nervous  system,  which 
are  usually  delayed  to  an  advanced  period  of  life,  occurring  al- 
together  prematurely,  and  bringing  with  them  a  kind  of  neu- 
ralgic pain  which  is  far  more  common  in  the  decline  than  in 
morning  of  life .  It  v/ill  be  seen  presently  that  functional  de' 
rangements  may  be  in  like  manner  precociously  induced,  with 
the  parallel  effect  of  inducing  such  pains  as  are  ordinarily  the 
product  of  a  later  epoch. 

From  the  moment  that  puberty  arrives  all  is  changed  in  the 
status  of  the  nervous  system.  In  the  stir  and  tumult  which 
pervade  the  organism,  and  especially  in  the  enormous  diversion 
of  its  nutritive  and  formative  energy  to  the  evolution  of  the 
generative  organs  and  the  correlative  sexual  instincts,  the  deli- 
cate apparatus  of  the  nervous  system  is  apt  to  be  overwhelmed, 
or  left  behind,  in  the  race  of  development.  Under  these  cir- 
cumstances, the  tendency  to  neuralgic  affections  rapidly  in- 
creases. It  will,  however,  be  seen  later  that  there  is  f\  great 
preponderance  of  particular  varieties  of  the  disease  during  this 
time.  This  period  is  above  all  things  fruitful  in  trigeminal 
neuralgias,  especially  migraine. 

There  remains  to  be  noticed  the  fact  that  sexual  precocity 
sometimes  veiy  much  anticipates  the  peculiar  characteristics 
of  the  period  after  puberty.  It  is  well  known  that  in  too  many 
instances  children  are  led,  by  the  almost  irresistible  influence 
of  bad  example,  to  indulge  in  thoughts  and  practices  which 
are  thoroughly  unchildish,  and  which  exercise  a  powerfully 
disturbing  influence  upon  the  nervous  system.  A  child  before 
the  age  of  puberty  ought  to  be  distinguished  (if  moderately 
healthy  in  other  respects)  by  the  absence  of  any  tendency  to 
dwell  upon  his  own  bodily  health.  Under  the  influence  of 
precocious  sexual  irritation  he  becomes  hypochondriacal  and 
self-centred,  and  often  suffers,  not  merely  from  fanciful  fears 
and  fanciful  pains,  but  from  actual  neuralgia,  which  is  some- 
times severe.     The  attacks  of  migraine  which  are  a  frequent 


24  ON  NEURALGIA. 

affection  of  delicate  children  whose  ]3ixberty  occurs  at  the  nor- 
mal time,  are  a  much  earlier  torment  with  children  Yrho  have 
early  become  addicted  to  bad  practices.  It  is  an  anticipatory  ef- 
fect upon  the  constitution,  strictly  analogous  to  the  j^roduc- 
tion  of  the  so-called  "hysteria  "in  little  girls  under  similar 
circumstances ;  and  I  suppose  there  is  no  physician  who  has 
not  once  or  twice,  at  least,  met  with  cases  of  the  latter  kind. 
The  existence  of  any  severe  neuralgic  affection  in  a  yomig  child, 
if  it  cannot  be  traced  to  tuburcle  or  other  recognizable  or  organic 
brain-disease  is  prhna-facie  ground  for  suspicion  of  precocious 
sexual  irritation;  though,  as  Dr.  Hillier's  cases  show,  it  is  oc- 
casionally produced  otherwise.  Usually,  there  are  other  fea- 
tures which  assist  in  the  discover}^  of  precocious  sexualism, 
when  it  exists  ;  there  is  a  morbid  tendency  to  solitary  moping, 
and  a  moral  change  in  which  untruthfulness  is  conspicuous. 

3.  Neuralgias  of  the  Middle  Period  of  Life. — By  this  period 
is  meant  the  tune  included  between  the  twenty-fifth  and  about 
the  fortieth  or  forty-fifth  year.  It  is  the  time  of  life  during 
which  the  individual  is  subjected  to  the  most  serious  pressure 
from  external  influences.  The  men,  if  poor,  are  engaged  in 
the  absorbing  struggle  for  existence,  and  for  the  maintenance 
of  their  families;  or,  if  rich  and  idle,  are  immersed  in  dissipa- 
tion, or  haunted  by  the  mental  disgust  which  is  generated  by 
ennui.  The  women  are  going  through  the  exhausting  process 
of  child-bearing,  and  supporting  the  mimerous  cares  of  a  poor 
household,  in  .some  cases ;  or  are  devoured  with  anxiety  for  a 
certain  position  in  fashionable  society  for  themselves  and  their 
children;  or  again,  they  are  idle  and  heart-weary,  or  con- 
demned to  an  unnatural  celibacy.  Very  often  they  are  both 
idle  and  anxious. 

It  must  not  be  supposed  that  there  is  a  sharp  line  of  demar- 
cation between  this  period  and  the  last;  nevertheless,  there 
are  certain  well-marked  differences,  both  in  their  general  ten- 
dencies, and  as  regards  the  local  varieties  which  are  com- 
monest in  each.  We  shall  discuss  the  latter  point  farther  on. 
At  present,  it  is  interesting  to  remark  on  the  general  freedom 
of  the  busy  middle  period  of  life  from  first  attacks  of  neural- 
gia. A  person  who  has  had  neuralgia  previously  may,  and 
very  likely  will,  during  this  epoch,  be  subject  to  recurrence  of 
the  old  affection  under  stress  of  exhaustion  of  any  kind.  But 
it  is  very  rare,  in  my  experieiice,  for  busy  house-mothers  or 
fatliers  of  families  to  get  first  attacks  of  neuralgia  during  tliis 
period  of  life.  It  is  not  the  way  in  which  a  still  vigorous 
man's  nervous  system  breaks  down,  if  it  breaks  down  at  all. 
Men  frequently  do  break  down,  of  course,  at  an  age  when  their 
tissues  generally  are  sound  enough,  and  there  is  no  reason,  ex- 
cept on^the  side  of  their  nervous  system,  why  they  should  not 
remain  in  vigorous  health  for  years.  Biit  it  is  greatly  more 
common  for  the  nervous  collapse  to  take  the  form  of  insanity, 


ON  NEURALGIA.  25 

or  hypochondriasis,  or  paralysis,  then  that  of  neuralgia.  If  a 
man  has  escaped  the  latter  disease  during-  the  period  when  the 
growth  of  his  tissues  was  active,  it  is  not  very  often  that  he 
falls  a  victim  to  it  till  he  begins,  physiologically  speaking,  to 
grow  old. 

4.  Neuralgias  of  Declining  Bodily  Vigor. — The  period  here 
referred  to  is  that  which  commences  with  the  first  indications 
of  general  physical  decay,  of  which  the  earliest  which  we  can 
recognize  (in  persons  who  are  not  cut  off  by  special  diseases)  is 
perhaps  the  tendency  to  atheromatous  change  in  the  arteries. 
The  first  development  of  this  change  varies  very  considerably 
in  date ;  but  whenever  it  occurs  it  is  a  plain  warning  that  a  new 
set  of  vital  conditions  has  arisen,  and  especially  notable  is'  its 
connection  with  the  characters  of  the  neuralgic  affections 
which  take  their  rise  after  its  commencement.  The  period  of 
declining  life  is  preeminently  the  time  for  severe  and  intract- 
able neuralgias.  Comparatively  few  patients  are  ever  perma- 
nently cured  who  are  first  attacked  with  neuralgia  after  they 
have  entered  upon  what  may  be  termed  the  ' '  degenerative  " 
period  of  existence.  I  mentioned  the  existence  of  commencing 
arterial  degeneration  as  the  special  and  most  trustworthy  sign 
of  the  initiation  of  bodily  decay ;  but  it  is  needless  to  say  that 
this  change  is  often  not  to  be  detected  in  its  earliest  stage. 
Something  has  been  done  of  late  years,  however,  to  render  its 
diagnosis  more  easy.  Not  to  dwell  upon  the  phenomenon  of 
the  arcus  senilis,  which  though  of  a  certain  value  is  confessedly 
only  very  partially  reliable,  we  may  mention  the  sphygmo- 
graphic  character  of  the  pulse  as  posessing  a  real  value  in  de- 
ciding the  physiological  status  of  the  arterial  system.  There 
is  a  well-known  form  of  pulse-curve,  square-headed,  with 
marked  lengthening  of  the  first  or  systolic  xsortion  of  the  wave, 
and  with  an  almost  total  absence  of  dicrotism,  even  when  the 
circulation  is  rapid,  which  will  often  seem  to  assure  us  that 
atheromatous  change  of  the  arterial  system  has  commenced, 
even  when  the  physical  characters  of  inelastic  artery  are  not  to 
be  recognized  with  the  finger  in  any  of  the  superficial  vessels 
by  the  touch  of  the  finger.  Indeed,  the  latter  test  is  in  all 
cases  far  less  reliable  than  the  sphy/mographic  trace,  except 
when  the  arjerial  change  has  proceeded  to  a  very  marked  de- 
gree of  development. 

To  a  certain  extent,  the  presence  or  absence  of  gray  hair  is 
of  value  in  deciding  whether  physiological  degeneration  has 
begun.  Like  the  arcus  senilis,  however,  this  is  only  reliable 
when  joined  with  other  indications,  for  it  may  be  a  purely 
local  and  separate  change,  having  nothing  to  do  with  the  gen- 
eral vital  status  of  the  body. 

5.  Neuralgias  which  are  immediately  excited  by  Aticemia 
or  Mal-mitrition. — Of  the  neuralgic  affections  which  can  be 
reckoned  in  this  class,  the  sole  characteristic  worthy  of  note  is 


26  ox   XEURALGLA.. 

the  circumstances  in  \vliicli.  ther  arise.  It  TVDuld  seem  that 
anaemia  and  mal-nutrition  simply  aggravate  the  tendency  of 
existing  weak  portions  of  the  nervous  system  to  be  affected 
vrith  pain ;  just  as  they  notoriously  do  aggi'avate  lurking  ten- 
dencies to  convulsion  and  spasm.  It  is  very  common,  for  in- 
stance, for  -women  to  suffer  severely  from  migraine,  and  other 
forms  of  neuralgia,  after  a  confinement  in  ■which  they  have 
lost  much  blood.  According  to  my  ovra  experience,  however, 
those  patients  ai'e  generally,  rf  not  invaiiably,  found  to  have 
previously  suffered  more  or  less  severe  neuralgic  pain,  at  some 
time  or  other  in  then*  liistory,  in  the  same  neiwes  which  now, 
under  the  depressing  influence  of  hcemorrhage,  have  become 
neuralgic.  One  of  the  very  "worst  cases  of  clavus  whl  ch  I  ever 
saw  happened  after  haemorrhage  in  labor ;  the  pain  was  so 
severe  and  prostrating  that  it  appeared  likely  the  patient  would 
become  insane.  I  discovered,  on  inquuy,  that  this  woman 
had  been  hable  for  many  years  to  headache  affecting  precisely 
the  same  region,  on  the  occasion  of  any  unusual  fatigne  or  ex- 
citement. 

There  is,  however,  one  variety  of  neuralgia  from  mal-nutri- 
tion which  deserves  special  consideration,  viz.,  that  which  is 
occasionally  produced  as  an  after-effect  of  merciu'ial  salivation. 
I  have  only  seen  one  instance  of  this  affection,  but  several 
are  recorded.  [Such,  at  least,  is  my  unpression,  but  I  have 
not  been  able  to  find  the  reports  of  them.]  My  patient  was  a 
woman  of  somewhat  advanced  yeai's  when  she  lu'st  came 
under  my  notice,  but  her  malady  had  (though  with  long 
intermissions)  existed  ever  since  she  was  a  young  girl  in 
service.  At  that  early  date  she  was  severely  salivated  by  some 
energetic  but  misguided  practitioner,  for  an  affection  which 
was  called  pleurisy,  biit  (according  to  her  description)  might 
well  have  been  only  pleurodynia,  to  which  servant  ghls  are  so 
very  subject.  At  any  rate,  the  consequences  of  the  medication 
were  most  disastrous.  Not  only  did  she  then  and  there  lose 
every  tooth  in  her  head  and  suffer  extensive  exfoliations  from 
the  maxilla?,  but  after  this  process  was  over  she  began  to  suffer 
frightfully  from  neuralgic  pains  in  both  arms  and  in  both  legs. 
Tonic  methcines  and  a  change  to  sea-air  brought  about  a  tardy 
and  temporary  cure :  but  from  that  moment  her  nervous  sys- 
tem never  recovered  itself.  TThenever  she  took  cold,  or  v.-as 
over-fatigued,  or  depressed  from  any  bodily  or  mental  cause, 
she  was  certam  to  experience  a  reciu'rence  of  the  pains.  At 
the  time  of  her  apphcation  to  me  she  was  suffering  from  an 
attack  of  more  than  ordinary  severity,  and  which  had  lasted  a 
long  time  without  showing  any  signs  of  yielding.  She  aj^par- 
ently  could  not  find  words  to  express  the  acuteness  of  her  suf- 
fei'ings.  All  along  the  coui'se  of  the  sciatic  nerve  in  the  thigh, 
all  do^^■n  the  course  of  the  middle  cutaneous  and  long  saphe- 
nous branches  of  the  anterior  croi-al,  in  the  musculo-sph*al, 


ON  NEURALGIA.  '^'H 

radial,  and  the  course  of  the  uhiar  nerves,  and  also,  in  a  more 
generalized  way,  in  the  gastrocnemii,  in  the  soles  of  the  feet, 
and  in  the  palms  of  the  hands,  the  pains  were  of  a  tearmg 
character,  which  she  described  as  resembling  ' '  iron  teeth " 
tearing  the  flesh.  The  pains  recurred  many  times  daily ;  her 
life  was  a  perfect  burden  to  her,  and  always  had  been  during 
these  attacks.  This  patient  was  under  my  observation,  on  va- 
rious occasions,  during  several  years,  and  I  established  the  fact 
that  cod-liver  oil  always  did  very  great  good.  But  it  was  evi- 
dent that  nothing  would  remove  the  tendency  to  the  recur- 
rence of  the  pains.  I  should  mention,  as  additional  proof  of 
the  extent  to  which  the  mercurial  poison  had  shattered  the 
nervous  system  of  this  woman,  that  she  had  violent  muscular 
tremors  at  the  time  of  her  first  attack,  and  on  several  subse- 
quent occasions.  A  more  completely  ruined  life  was  never 
seen ;  the  poor  woman  had  been  on  the  highway  to  promotion 
in  the  service  of  a  nobleman  when  she  was  mercurialized,  but 
her  whole  prospects  were  blighted  by  the  serious  danger  to  her 
health  which  was  caused  by  the  preposterous  antiphlogisticism 
of  her  medical  attendant. 

I  do  not  know  that  the  poisonous  action  of  any  other  metalic 
poison  than  mercury  has  been  distinctly  shown  to  produce 
neuralgic  pains  of  superficial  nerves.  The  action  of  lead  is 
well  known  to  produce  colic,  a  disease  which  will  be  specially 
dwelt  on  elsewhere.  And  undoubtedly  a  certain  amount  of 
aching  pam  sometimes  attends  certain  stages  of  lead-palsy  of 
the  extensor  muscles  of  th©  forearm.  But  I  know  of  no  facts 
pointing  to  a  true  saturnine  neuralgia.  And  the  chronic 
poisonous  effects  of  arsenic  on  the  nervous  system  seem  to 
produce  sensory  paralysis,  rather  than  pain. 

We  come  now  to  the  consideration  of  the  local  varieties  of 
neuralgia.  The  primary  subdivision  of  them  may  be  made  as 
follows : 

I.  Superficial  Neuralgias.     II.  Visceral  Neuralgias. 

I.  Of  superficial  neuralgias  a  further  classification  may  he 
made : 

(a)  Neuralgia  of  the  fifth  (trigeminal,  or  trifacial). 

(6)  Cervico-occipital  neuralgia. 

(c)  Cervico-brachial  neuralgia. 

{d)  Intercostal  neuralgia. 

(e)  Lumbo-abdominal  neuralgia 

(/)  Crural  neuralgia. 

{g)  Sciatic  neuralgia. 

This  arrangement  is  that  of  Valleix,  and  appears  to  me  suh- 
stantially  correct. 

(a)  The  most  important  group  of  neuralgias  are  those  of  the 
fifth  cranial  nerve. 

Neuralgia  of  the  fifth  nerve  always  exhibits  itself  in  the 
especial  violence  in  certain  foci,  wliich  Valleix  was  the  first  to 


28  ON  NEURALGIA.. 

define  with  accuracy.  These  foci  are  always  in  points  where 
the  nerve  becomes  more  superficial,  either  in  turnmg  out  of  a 
bony  canal,  or  in  penetratiag  fasciae.  In  the  ophthalmic 
division  of  the  nerve  the  following-  possible  foci  are  noticeable : 
(1)  The  supra-orbital,  at  the  notch  of  that  name,  or  a  little 
higher,  in  the  course  of  the  frontal  nerve ;  (2)  the  palpebral,  in 
the  upper  eyelid ;  (3)  the  nasal,  at  the  point  of  emergence  of 
the  long  nasal  branch,  at  the  junction  of  the  nasal  bone  with 
the  cartilage;  (4)  the  ocular,  a  somewhat  indefinite  focus 
wnthin  the  globe  of  the  eye ;  (5)  the  trochlear,  at  the  inner  angle 
of  the  orbit. 

In  the  superior  maxillary  division  the  foUowmg  foci  may  be 
found:  (1)  The  infra-orbital,  corresponding  to  the  emergence 
of  the  nerve  of  that  name  from  its  bony  canal;  (2)  the  malar, 
on  the  most  prominent  portion  of  the  malar  bone ;  (3)  a  vague 
and  indeterminate  focus,  sone where  on  the  line  of  the  gums  of 
the  upper  jaw;  (4)  the  superior  labial,  a  vague  and  not  of  ten 
important  focus;  (5)  the  palatine  point,  rarely  observed,  but 
occasionally  the  seat  of  intolerable  pain. 

In  the  inferior  maxillary  division  the  foci  are :  (1)  The  tem- 
poral, a  point  on  the  auriculo-temjjoral  branch,  a  little  in  front 
of  the  ear ;  (2)  the  inferior  dental  pomt,  opposite  the  emergence 
of  the  nerve  of  that  name ;  (3)  the  lingual  point,  not  a  common 
one,  on  the  side  of  the  tongue ;  (4)  the  inf er'ior  labial  point, 
only  rarely  met  with. 

Besides  these  foci  in  relation  with  distinct  branches  of  the 
trigeminus,  there  is  one  of  especial  frequency  which  corres- 
ponds to  tlae  inosculation  of  various  branches.  This  is  the 
parietal  point,  situated  a  little  above  the  parietal  eminence.  It 
is  small  in  size — the  point  of  the  little  finger  would  cover  it. 
It  is  the  commonest  focus  of  all. 

Neuralgia  may  attack  any  one,  or  all,  of  the  three  divisions 
of  the  nerve ;  the  latter  event  is  comparatively  rare.  Valleix, 
indeed,  holds  a  different  opinion ;  but  this  seems  to  me  to  arise 
from  the  fact  that  his  definition  of  neuralgia  was  too  narrow 
to  include  a  large  number  of  the  railder  cases  of  neuralgia, 
which  are,  nevertheless  I  believe,  decidedly  of  the  same  essen- 
tial character  with  the  severer  affections.  The  most  frequent 
occurrence  is  the  limitation  of  the  pain  to  the  ophthalmic 
division,  and  incomparably  the  most  frequent  foci  of  pain  are 
the  supra-orbital  and  the  parietal. 

The  most  common  variety  of  trigeminal  neuralgia  is 
migraine,  or  sick-headache,  as  it  is  often  called.  This  is  an  af- 
fection which  is  entirely  independent  of  digestive  disturbances, 
m  its  primary  origin,  though  it  may  be  aggravated  by  their 
occurrence.  It  almost  always  first  attacks  individuals  at  some 
time  during  the  period  of  bodily  development.  Under  the  in- 
fluences proper  to  this  vital  epoch,  and  often  of  a  fui'ther  de- 
bility produced  by  a  premature  strauaing  of  the  mental  powers, 


ON  NEURALGIA,  29 

the  patient  begins  to  suffer  headache  after  any  unusual  fatigue 
or  excitement,  sometimes  without  any  distinct  cause  of  this 
kind.  The  unilateral  character  of  this  pain  is  not  always  de- 
tected at  firet ;  but,  as  the  attacks  increase  in  frequency  and 
severity,  it  becomes  obvious  that  the  pain  is  limited  to  the 
supra-orbital  and  its  tAngs,  with  sometimes  also  the  ocular 
branches.  In  rare  cases,  as  in  all  forms  of  nem-algia,  the 
nerves  of  both  sides  may  be  affected ;  I  have  already  observed 
that  this  seems  to  be  relatively  more  common  in  young 
children.  If  the  pain  lasts  for  any  considerable  length  of  time, 
nausea,  and  at  length  vomiting,  are  induced.  This  Ls  followed 
at  the  moment  by  an  mcrease  in  the  severity  of  the  pain,  ap- 
parently from  the  shock  of  the  mechanical  effect ;  but  from 
this  point  the  violence  of  the  affection  begins  to  subside,  and 
the  patient  usually  falls  asleep.  Tlie  liistory  of  the  attacks 
negatives  the  idea  that  the  vomiting  is  ordinarily  remechal. 
Tins  symptom  merely  mdicates  the  lowest  iDoint  of  nervous  de- 
pression ;  but  it  may  happen  that  a  quantity  of  food  which  has 
been  mjudiciously  taken,  lying  as  it  does  undigested  in  the 
stomach,  may  of  itself  greatly  aggravate  the  neuralgia,  by  irri- 
tation transmitted  to  the  medulla  oblongata.  In  such  a  case 
vomiting  may  dhectly  relieve  the  nerve-pain.  Wlien  the 
patient  awakes  from  sleep,  the  active  pain  is  gone.  But  it  is  a 
connnon  occurrence — indeed  it  always  happens  when  the  neu- 
ralgia has  lasted  a  long  time — that  a  tender  condition  of  the 
superficial  parts  remains  for  some  horn's,  perhaps  for  a  day  or 
two.  This  tenderness  is  usually  somewhat  diffused,  and  not 
lunited  with  accuracy  to  the  foci  of  greatest  pain  during  the 
attacks. 

Sick  headache  is  not  u^acommonly  ushered  in  by  sigliings, 
yawning,  and  shuddering — symptoms  which  remind  us  of  the 
prodromata  of  certain  graver  neiu'oses,  to  which,  as  we  shall 
hereafter  see,  it  is  probably  related  by  hereditary  descent,  in 
its  severer  forms,  migraine  is  a  terrible  infliction;  the  pain 
gradually  spreads  to  every  twig  of  the  ophthalmic  division ; 
the  eye  of  the  affected  side  is  deeply  bloodshot,  and  streams 
with  teal's ;  the  eyehd  droo^DS,  or  jerks  convulsively :  the  sight 
is  clouded,  or  even  fails  almost  altogether  for  the  time,  and 
the  darts  of  agony  vdiich  shoot  up  to  the  vertex  seem  as  if  the 
head,  were  bemg  split  down  with  an  axe.  The  patient  cannot 
bear  the  least  glimmer  of  light,  nor  the  least  motion,  but  lies 
quite  helpless,  mtensely  chilly  and  depressed,  the  pulse  at  fu'st 
slow,  small  tuid  wiry,  afterward  more  rapid  and  larger,  but 
very  compressible.  The  feet  are  genei'ally  actually,  as  well  as 
subjectively,  cold.  Very  often,  toward  the  end  of  the  attack, 
there  is  a  large  excretion  of  pale,  limpid  urme. 

Another  variety  of  trigeminal  neui'algia  which  infests  the 
period  of  bodily  develox^ment  is  that  known  as  clavus  hysteri- 
cus :  clavus,  from  the  fact  that  the  pain  is  at  once  severe,  and 


30  ON  NEURALGIA. 

limited  to  one  or  two  small  definite  points,  as  if  a  nail  or  nails 
were  bemg-  driven  into  the  skull.  These  x^oints  correspond 
either  to  the  supra-oi'bital  or  the  parietal,  or,  as  often  happens, 
to  both  at  once.  But  for  the  gi'eater  limitation  of  the  area  of 
pain  in  clavus,  that  affection  would  have  little  to  distinguish  it 
from  raigi'aine,  for  the  former  is  also  accompanied  with  nausea 
and  vomitmg  when  the  pain  continues  long  enough ;  and  in 
both  instances  it  is  obvious  that  there  is  a  reflex  irritation  pro- 
pagated from  the  pamful  nerve.  The  adjective  hystericus  is 
an  improper  and  inadequate  definition  of  the  circumstances 
under  which  clavus  arises.  The  truth  is,  that  the  subjects  of 
it  are  chiefly  females  who  are  passing  through  the  trying  period 
of  bodily  development ;  but  there  is  no  evidence  to  show  that 
uterine  disorders  give  any  special  bias  toward  this  complaint. 
Both  migraine  and  clavus  are  often  met  with  in  persons  who 
have  long  passed  their  youth;  but  their  first  attacks  have 
nearly  always  occurred  during  the  period  of  development. 

One  circumstance  in  connection  with  well-marked  clavus 
appears  worth  noting,  as  somewhat  differentiatuig  it  from 
migraine.  It  is,  I  think,  decidedly  more  frequently  the  imme- 
diate consequence  of  ansemia  than  thej';  but  it  does  not  ap- 
pear, from  my  experience,  that  the  chlorotic  form  of  anaemia 
is  any  more  provocative  of  it  than  is  aneemia  from  any  other 
cause.  Some  of  the  worst  cases  of  clavus,  probably,  that  have 
ever  been  seen  were  developed  in  the  old  days  of  phlebotomy. 
It  was  then  very  common  for  a  delicate  gu'l,  on  complaint  of 
some  stitch  of  neui^lgia  or  muscular  pain  in  the  side,  to  be 
immediately  bled  to  a  large  extent,  with  the  idea  of  checking 
an  imaginary  commencing  pleurisy.  The  treatment,  so  far 
from  curing  the  pain  and  the  dyspepsia  (which  it  produced), 
often  aggravated  them ;  whereupon  the  signs  of  inflaunnation 
were  thought  to  be  still  more  manifest,  and  more  blood  was 
taken.  Under  such  circumstances  the  most  complete  anaemia 
was  develoi^ed,  and  very  often  the  patient  became  a  martyr  to 
clavus  in  its  severest  fonns.  One  does  not  now  very  frequently 
meet  with  the  victims  of  such  mistaken  practice ;  but  I  have 
seen  one"  [since  writing  this  I  have  seen  another  case  (vide  car- 
diac neuralgia,  infra)']  very  severe  case  of  clavus  produced  by 
loss  of  blood  (in  a  subject  who  was  doubtless  predisposed  to 
neuralgic  affections,  to  judge  from  his  family  history).  The 
case  was  that  of  a  boy  who  accidentally  divided  his  radial. 

The  middle  period  of  life  is  not,  according  to  my  experience, 
fruitful  in  firet  attacks  of  trigeminal  neuralgia.  But,  when 
the  neuralgic  tendency  has  once  declared  itself,  there  are  many 
cu^cumstances  of  middle  adult  life  which  tend  to  recall  it. 
Over-exertion  of  the  mind  is  one  of  the  most  frequent  causes, 
especially  when  this  is  accompanied  by  anxiety  and  worry; 
indeed,  the  latter  has  a  worse  influence  than  the  former.  In 
women,  the  exhaustion  of  h^emorrliageal  parturition,   or  of 


ON  NEURALGIA,  31 

menorrhagia,  and  also  the  depression  proauced  by  over-suck- 
ling, are  frequent  causes  of  the  recurrence  of  a  migraine  or 
clavus  to  which  the  patient  had  been  subject  when  young. 
The  middle  period  of  life  is  very  obnoxious  to  severe  mental 
shocks,  which  are  more  injurious  than  in  youth,  because  of  the 
diminished  elasticity  of  mind  which  now  exists ;  and  the  same 
may  be  said  of  the  influence  of  severe  bodily  accident  of  a 
kind  to  inflict  damage  on  the  central  nervous  system.  Special 
mention  ought  to  be  made,  in  the  case  of  women,  of  the  dis- 
turbing influence  of  the  series  of  changes  which  close  the  mid- 
dle portion  of  their  life,  viz.,  the  involution  of  the  sexual 
organs.  It  would  seem  as  if  every  evil  impression  which  has 
ever  been  made  on  the  nervous  system  hastens  to  revive,  with 
all  its  disastrous  effects,  at  this  crisis.  Latent  tendencies  to 
facial  neuralgia  are  particularly  apt  to  reassert  their  existence, 
and  they  are  usually  accompanied  and  aggravated  by  a  ten- 
dency to  vaso-motor  disturbance,  which  not  unfrequently 
seems  to  be  the  most  distressing  part  of  the  malady.  I  have 
several  times  been  consulted  by  women  undergoing  the 
"change,"  whose  chief  complaint  was  of  disagreeable  flush- 
ings and  chills,  especially  of  the  face ;  and,  on  inquiring  fur- 
ther, one  has  found  that  they  were  suffering  from  severe  facial 
neuralgia,  which,  however,  alarmed  and  distressed  them  less 
than  did  the  vasomotor  disturbance,  and  the  giddiness,  etc., 
which  were  an  evident  consequence  of  it. 

It  is,  however,  the  final  or  degenerative  period  of  life  which 
produces  the  most  formidable  varieties  of  facial  neuralgia. 
Neuralgia  of  the  fifth,  which  have  previously  attacked  an  in- 
dividual, may  recur  at  this  time  of  life  without  any  special 
character,  except  a  certain  increase  of  severity  and  obstinacy. 
But  trigeminal  neuralgias,  which  now  appear  for  the  first  time, 
are  usually  intensely  severe,  and  nearly  or  quite  incurable. 
These  cases  correspond  with  the  affection  named  by  Trousseau 
tic  epileptiforme,  and  it  is  of  them,  doubtless,  that  Romberg  is 
speaking,  when  he  says  that  the  true  neuralgias  of  the  fifth 
rarely  occur  before  the  fortieth  year  of  life.  These  neuralgias 
are  distinguished  by  the  intense  severity  of  the  pain,  the  light- 
ning-hke  suddenness  of  its  onset,  and  the  almost  total  impossi- 
bility of  effecting  more  than  a  temporary  palliation  of  the 
symptoms.  But  they  are  also  distinguished  by  another  cir- 
cumstance which  too  often  escapes  attention,  namely,  they  are 
almost  invariably  connected  with  a  strong  family  taint  of  in- 
sanity, and  very  often  with  strong  melancholy  and  suicidal 
tendencies  in  the  patient  himself,  which  do  not  depend  on,  and 
are  not  commensurate  with,  the  severity  of  the  pain  which  he 
suffers.  It  may  seem  a  strong  view  to  take,  but  I  must  say 
that  I  regard  a  well-developed  and  typical  neuralgia,  of  the 
type  we  are  now  speaking  of,  as  an  affection  in  which  the  men- 
tal centres  are  almost  as  deeply  involved  as  in  the  fifth  nerve 


32  ON  NEURALGIA. 

itself;  though,  whether  this  is  an  original  part  of  the  disease, 
or  a  mere  reflex  effect  of  the  affection  of  the  trigeminal  nerve, 
I  am  not  prepared  to  say.  Other  reflex  affections  are  common 
enough  in  this  kind  of  facial  neuralgia,  and  esi^ecially  spasmo- 
dic, contractions  of  the  facial  muscles,  Avhich,  indeed,  often 
fonn  one  of  the  most  striking  features  of  the  malady,  the  at- 
tacks of  i)ain  being  accomj)anied  by  hideous  involuntary  grim- 
aces. Even  in  the  earlier  stages  of  the  disease  there  is  usually 
some  degree  of  the  same  thing,  as,  for  instance,  sj)asmodic 
winking.  In  the  great  majority  of  cases,  after  a  little  time, 
exquisitely  tender  points  are  formed  in  the  chief  foci  of  jiam;  in 
the  intervals  between  the  spasms  the  least  pressure  on  these 
points  is  sufficient  to  cause  agony,  and  a  mere  breath  of  wind 
impmging  on  them  will  often  reproduce  the  spasm.  Yet,  in  the 
height  of  the  acute  pai'oxysm  itself,  the  patient  will  often  fran- 
tically rub  these  very  parts  in  the  A^ain  attempt  to  produce  ease; 
and  it  has  often  been  noticed  that  such  friction  has  completely 
rubbed  off  the  hah  or  Avhisker  on  the  affected  side :  this  hap- 
pens the  more  easily,  because  the  neuralgic  affection  itself  im- 
pair the  nutrition  of  the  hau'  and  makes  it  more  brittle,  as  we 
shall  haA'e  occasion  to  show  more  fully  hereafter.  The  general 
appearance  of  a  confirmed  neuralgic  of  the  type  now  descril^ed 
is  A'ery  distressing,  and  the  history  of  his  case  fully  corresponds 
to  it.  He  is  moody  and  depressed,  he  dreads  the  least  move- 
ment, and  the  least  cvxrrent  of  air ;  he  hardly  dares  masticate 
food  at  all,  more  especially  if  the  mferior  maxillary  division  of 
the  nerve  be  implicated  (as  is  generally  the  case  sooner  or  later), 
for  this  movement  re-excites  the  pain  with  great  violence. 
Nutrition  is  very  commonly  kept  up  by  slops,  and  is  thus  very 
insufficiently  mamtamed :  this  failure  of  nutrition  is  itself  a 
decidedly  powerful  influence  in  aggi'avatmg  the  disease.  And 
there  is  a  still  further  calamity  which  is  not  unlikely  to  occur. 
The  patient  may  fly  to  the  stupefaction  of  di'ink  as  a  relief  to 
his  sufferings,  and.  if  he  has  once  exx^erienced  the  temx^orary 
comfort  of  drunken  ana?sthesia,  is  excessiA^ely  likely  to  repeat 
the  experiment.  But  this  is  another  and  one  of  the  most 
fatally  certain  methods  of  hastenmg  degeneration  of  nerve- 
centres,  and  the  ultimate  effect,  therefore,  is  disastrous  in 
every  way. 

Afthough  the  neuralgias  of  the  degenerative  period  are  thus 
fatally  progressive,  on  the  whole,  there  are  some  curious  occa- 
sional anomalies.  Many  cases  are  recorded,  and  I  have  myseK 
seen  such,  in  Avhicli  the  attacks  of  pain,  after  reaching  a  very 
considerable  degree  of  intensity,  have  ceased  for  many  months, 
whether  under  the  influence  of  remedies  or  not  it  is  difficult  to 
say  with  certainty,  but  probably  far  more  from  independent 
causes.  TTliatever  may  be  the  reason  of  these  sudden  arrests, 
however,  certain  it  is  that  they  are  very  seldom  permanent,  the 
pain  returning  sooner  or  later,  like  an  inexorable  fate. 


ON  NEURALGIA.  33 

(b)  Cervico-occipital  Neuralgia. — As  Valleix  has  remarked, 
there  are  sevei'al  nerves  (in  fact,  the  posterior  branches  of  all 
the  first  four  spinal  pairs)  wliicli  are  niore  or  less  frequently 
the  seat  of  this  affection.  But  among  them  all  there  is  none 
comparable  to  the  great  occipital,  which  arises  from  the  second 
si)inal  pair,  for  the  frequency  and  impoi'tance  of  its  neuralgic 
affections.  This  nerve  sends  branches  to  the  "vvhole  occipital 
and  the  posterior  parietal  region.  On  the  other  hand,  the  sec- 
ond and  third  spinal  nerves  help  to  make  up  the  superficial 
cervical  branch  of  the  cervical  plexus  which  is  distributed  to 
the  triangle  between  the  jaw,  the  median  line  of  the  neck,  and 
the  edge  of  the  stern o-mastoid,  and  those  to  the  lower  part  of 
the  cheek.  Then  there  is  the  auricular  branch,  which  starts 
from  the  same  two  pairs,  and  supplies  the  face,  the  parotid  re- 
gion, and  the  back  of  the  external  ear.  Then  the  small  occi- 
pital, distributed  to  the  ear  and  to  the  occij^ut.  And,  finally, 
superficial  descending  branches  of  the  plexus.  These,  alto- 
gether, are  the  nerves  which  at  various  points,  where  they  be- 
come more  superficial,  form  the  foci  of  cervico-occipital  neu- 
ralgia. 

The  most  typical  example  of  this  form  of  neuralgia  which 
has  fallen  under  my  notice  occurred  (after  exjwsure  to  cold 
v/ind)  in  a  lady-  about  sixty  years  of  age,  who  had  all  her  life 
been  subject  to  neuralgic  headache  approaching  the  type  of 
migraine,  and  wlio  came  of  a  family  in  which  insanity,  apo- 
plexy, and  other  grave  neuroses,  had  been  frequent.  The  pain 
centred  very  decidedly  in  a  focus  corresponding  to  the  occipital 
triangle  of  the  neck;  it  recurred  at  irregular  intervals,  and  in 
very  severe  paroxysms,  lasting  about  a,  minute.  It  was  inter- 
esting to  follow  the  histoiy  of  this  case  in  one  respect.  It 
afForcled  a  clear  illustration  of  the  manner  m  which  local  ten- 
derness is  developed ;  for  during  the  first  three  or  four  days  the 
patient,  so  far  from  complaining  that  the  painful  part  was  ten- 
der on  pressure,  experienced  decided  relief  from  pressure, 
although  she  experienced  none  from  m.ere  rest,  however  care- 
fully the  neck  might  be  supported.  But  in  the  course  of  a  few 
days  an  intensely  painful  spot  developed  itself  in  the  occipital 
triangle,  and  the  back  of  the  ear  became  excessively  tender. 
All  manner  of  remedies  had  been  tried  in  this  case,  without 
the  slightest  success  and  especially  there  w^as  a  large  amount 
of  speculative  medication,  on  the  theory  of  the  probably 
"rheumatic"  or  "gouty"  nature  of  the  affection.  Nothing 
w^as  doing  the  least  good  to  the  pain,  and  meantime  the  old 
lady's  digestion  and  general  health  and  spirits  Vv^ere  suffering 
very  seA^erely.  Blistering  was  now  suggested,  and  tlie  affec- 
tion yielded  at  once.  The  relief  afxorded  must  have  been  very 
complete,  to  judge  by  the  warm  gratitude  which  the  patient 
expressed.  The  subsequent  history  of  this  patient  iHustrates 
several  points  which  will  engage  our  attention  under  the  sec- 
3 


34  ON  NEURALGIA. 

tion  of  Pathology.  It  may  be  just  mentioned  here,  that  she 
sulfered,  twelve  months  later,  from  a  hemiplegic  attack  of 
paralysis. 

The  tendency  of  cervico-occipital  neuralgias  is  to  spread 
toward  the  lower  portions  of  the  face,  as  observed  by  Valleix ; 
in  this  case  they  become,  sometimes,  un distinguishable  from 
neuralgias  of  the  third  division  of  the  trigeminus.  In  the  early 
stages  of  the  disease,  if  the  physician  had  been  lucky  enough 
to  witness  them,  the  true  place  of  the  origin  of  the  pain  would 
have  been  easily  recognizable;  at  a  later  date  it  sometimes 
needs  great  care,  and  a  very  strict  interrogation  of  the  patient, 
to  discover  the  true  history  of  the  disease.  Sometimes,  even, 
a  cervico-occipital  neuralgia  which  spreads  in  this  way  causes 
great  irritation  and  swelling  of  the  submaxillary  and  cervical 
glands ;  and  I  have  known  a  case  of  this  kind  mistaken  for 
commencing  glandular  abscess.  The  pain  and  tension  were  so 
great  in  this  case,  and  the  constitutional  disturbance  was  so 
considerable,  that  the  presence  of  deep-seated  pus  was  strongly 
suspected,  and  the  propriety  of  an  incision  (which  would  have 
been  a  hazardous  proceeding)  was  seriously  canvassed. 

Experience  is  too  limited,  to  judge  by  what  I  have  personally 
seen,  and  the  recorded  cases  with  which  I  am  acquainted,  to 
enable  us  to  say  anything  with  confidence  of  the  conditions,  as 
to  age  and  general  nutrition  of  the  body,  which  specially  favor 
the  occurrence  of  cervico-occipita,l  neuralgia.  Apparently, 
however,  there  is  inuch  reason  for  thinking  that  the  immedi- 
ately exciting  cause  of  it  is  most  frequently  external  cold.  I 
have  known  it  produced  several  times  in  the  same  person,  by 
sitting  in  a  draught  which  blew  strongly  on  the  back  of  the 
neck.  And  I  am  inclined  to  think  that  it  is  sekloin  the  first 
form  of  neuralgia  which  attacks  a  patient,  but  usually  occurs 
in  those  who  have  previously  suffered  from  neuralgic  pains 
either  of  the  trigeminus  or  of  some  other  superficial  nerve.  I 
have  known  it  once  to  occur  in  a  person,  thus  predisposed  to 
neuralgic  affections,  in  consequence  of  reflex  irritation  from  a 
carious  tooth,  as  was  proved  by  its  cessation  on  the  extraction 
of  the  latter,  although  there  was  no  facial  pain. 

(.c)  Cervico-brachial  Neuralgia. — This  group  includes  all  the 
neuralgias  which  occur  in  nerves  originating  from  the  brachial 
plexus,  or  from  the  posterior  branches  of  the  four  lower  cervi- 
cal nerves.  The  most  important  characteristic  of  the  neural- 
gias of  the  upper  extremity  is  the  frequency,  indeed  almost 
constancy,  with  which  they  invade,  simultaneously  or  succes- 
sively, several  of  the  nerves  which  are  derived  from  the  lower 
cervical  pairs.  The  neuralgic  affections  of  the  small  posterior 
branches  (distributed  to  the  skin  of  the  lower  and  back  part  of 
the  neck)  are  comparatively  of  small  importance.  But  the 
"  solidarite, "  which  Valleix  so  well  remarked,  between  the 
various  branches  of  the  brachial  plexus,  causes  the  neuralgias 


ON  NEURALGIA.  35 

of  the  shoulder,  arm,  forearm,  and  hand  to  he  extremely 
troublesome  and  severe,  owing  to  the  numerous  foci  of  pain 
which  usually  exist.  Perhaps  Valleix's  description  of  these 
foci  is  someAviiat  over-fanciful  and  minute ;  but  the  following 
among  them  which  he  mentions  I  have  repeatedly  identified; 
(1)  An  axillary  point,  corresponding  to  the  brachial  plexus 
itself ;  (S)  a  scapular  point,  corresponding  to  the  angle  of  the 
scapula.  (It  is  difficult  to  identify  the  peccant  nerve  here;  the 
one  to  which  it  apparently  corresponds,  and  to  which  Valleix 
refers  it,  is  the  subscapular ;  but  we  are  accustomed  to  think  of 
this  as  a  motor  nerve.  Still,  it  is  certain  that  pressure  on  a 
painful,  point  existing  here  will  often  cause  acute  pain  in  the 
nerves  of  the  arm  and  forearm.)  (3)  A  shoulder  point,  which 
corresponds  to  the  emergence,  through  the  deltoid  muscle,  of 
the  cutaneous  filets  of  the  circumflex ;  (4)  a  median-cephalic 
point,  at  the  bend  of  the  elbow,  where  a  bi'anch  of  the  musculo- 
cutaneous nerve  lies  immediately  behmd  the  median-cephalic 
vein ;  (5)  an  external  humeral  point,  about  three  inches  above 
the  elbow,  on  the  outer  side,  correspondmg  to  the  emergence 
of  the  cutaneous  branches  which  the  musculo-spiral  nerve 
gives  off  as  it  lies  in  the  groove  of  the  humerus ;  (6)  a  superior 
ulnar  j)oint,  corresponding  to  the  course  of  the  ulnar  nerve  be- 
tween the  olecranon  and  the  epitrochlea;  (7)  an  inferior  ulnar 
point,  where  the  ulnar  nerve  passes  in  front  of  the  annular 
ligament  of  the  wrist;  (8)  a  radial  point,  marking  the  place 
where  the  radial  nerve  becomes  superficial,  at  the  lower  and 
external  aspect  of  the  forearm.  Besides  these  foci,  there  are 
sometimes,  but  more  rarely,  painful  points  developed  by  the 
side  of  the  lower  cervical  vertebi-ae,  corresponding  to  the  pos- 
terior branches  of  the  lower  cervical  pairs. 

The  most  common  seat  of  cervico-brachial  neuralgia  has 
been,  in  my  experience,  the  ulnar  nerve,  the  superior  and 
inferior  points  above  mentioned  being  the  foci  of  greatest 
intensity ;  an  axillary  point  has  also  been  developed  in  one  or 
two  cases  which  I  have  seen.  Rarely,  however,  does  the  neu- 
ralgia remain  limited  to  the  tilnar  nerve ;  in  the  majority  of 
cases  it  soon  spreads  to  other  nerves  which  emanate  from  the 
brachial  plexus.  A  very  common  seat  of  neuralgia  is  also  the 
shoulder,  the  affected  nerves  being  the  cutaneous  branches  of 
the  circumflex.  C  am  inclined  to  think,  also,  that  affections  of 
the  musculo-spiral,  and  of  the  radial  near  the  wrist,  are  rather 
connnon,  and  have  found  them  very  obstinate  and  difficult  to 
deal  with.  One  case  has  recently  been  under  my  care  in  which 
the  foci  of  greatest  intensity  of  the  pain  were  an  external 
humeral  and  a  radial  point ;  but  besides  these  there  was  an 
exquisitely  painful  scapular  point.  In  another  case  the  paiu 
commenced  in  an  external  humeral  and  a  radial  point,  but  sub- 
sequently the  shoulder  branches  of  the  circumflex  became 
involved.     A  most  plentiful  crop  of  herpes  was  an  intercurrent 


36  ON  NEURALGIA. 

phenomenon  in  this  case,  or  rather,  was  plainly  dependent  on 
the  same  cause  which  produced  the  neuralgia. 

Median  cephalic  neuralgia  is  an  affection  which  used  to  be 
comparatively  common  in  the  days  when  phlebotomy  was  in 
fashion,  the  nerves  being  occasionally  wounded  in  the  opera- 
tion. I  have  only  seen  it  in  connection  with  this  cause, 
that  is  to  say,  as  an  independent  affection.  One  such 
case  has  been  under  my  care.  But  a  slight  degree  of  it  is  not 
uncommon,  as  a  secondary  symptom,  in  neuralgia  affecting 
other  nerves.  The  traumatic  form  is  excessively  obstinate  and 
intractable. 

In  the  neuralgias  of  the  arm  we  begin  to  recognize  the  etio- 
logical characteristic  which  distinguishes  most  of  the  neural- 
gic affections  of  the  limbs,  namely,  the  frequency  Avith  which 
they  are  aggravated,  and  esj)ecially  with  which  they  are 
kept  uj)  and  revived  when  apparently  dying  out,  the  muscular 
movements.  In  the  case  above  referi'ed  to,  of  neuralgia  of  the 
subscapular,  musculo-spiral  (cutaneous  branches),  and  radial, 
the  act  of  inlaying  on  the  piano  for  half  an  hour  immediately 
revived  the  pains,  in  their  fullest  force,  when  convalescence 
had  apparently  been  almost  established. 

There  is  a  s^oecial  cause  of  cervico-brachial  neuralgias  which 
is  of  more  imiioi'tance  than,  till  quite  lately,  has  ever  been  rec- 
ognized, namely,  reflex  irritation  from  diseased  teeth.  The 
subject  of  these  reflex  affections  from  carious  teeth  has  been 
specially  brought  forwai'd  by  Mr.  James  Sa,11er,  in  a  very  able 
and  interesting  paper  in  tlae  "  G-uy's  Hospital  Reports"  for 
1867 ;  and  Mr.  Salter  informs  me  that  he  has  been  surprised  by 
the  number  of  cases  of  reflex  affectiojis,  both  paralytic  and 
neuralgic,  of  the  cervico-brachiaJ  nerves,  produced  by  this 
kind  of  irritation,  and  tluit  he  aga-ees  with  me  in  thinking  that 
a  peculiar  organization  or  disposition  of  the  spinal  centres  of 
these  nerves  must  be  assumed  in  order  to  account  for  the  fact. 

The  liabilit}^  of  particular  nerves  hi  the  upper  extremity  to 
neuralgia  from  external  injuries  requires  a  few  words.  The 
nerve  Avhich  is  probably  most  exposed  to  this  is  the  ulnar. 
Blows  on  what  is  vulgarly  called  the  funny-bone  are  not  un- 
common exciting  causes  of  neuralgia  in  predisposed  persons, 
and  cutting  wounds  of  the  ulnar  a  little  above  the  wrist  are 
rather  frequent  causes.  The  deltoid  branclj£S  of  the  circum-- 
flex  and  the  humeral  cutaneous  branches  of  uie  musculo-spiral 
are  much  exposed  to  bruises  and  to  cutting  wounds.  So  far  as 
I  laiow,  it  is  only  when  a  nerve  trunk  of  some  size  has  been 
wounded  that  neuralgia  is  a  probable  result.  "Wounds  of  the 
small  nervous  branches  in  the  flngers,  for  instance,  are  very 
seldom  followed  by  neuralgia.  I  have  no  statistics  to  guide  me 
as  to  the  effect  of  long-continued  irritatioji  applied  to  one  of  these 
small  iDcripheral  branches,  but  it  is  probable  that  that  might  be 
more  capable  of  inducing  neuralgia.     As  far  as  my  own  experi- 


ON  NEURALGIA.  37 

ence  goes,  however,  it  would  appear  that  a  more  common  result 
is  convulsion  of  some  kind,  from  reflex  irritation  of  the  cord. 

(cl)  DorsO' intercostal  Neuralgia. — This  is  one  of  the  com- 
monest varieties  of  neuralgia,  and  yet  it  is  very  likely  to  be 
confounded  with  other  affections  not  neuralgic  in  their  na- 
ture. Tli3  disorder  with  which  it  is  especially  liable  to  be  con- 
founded is  myalgia,  which  will  be  fully  described  in  another 
chapter,  and  which,  when  developed  in  the  region  of  the  body 
to  whicli  we  are  now-  referring,  is  commonly  spoken  of  as 
pleurodynia,  or  lumbago  (according  as  it  all'ects  the  muscles  of 
the  back  or  of  the  side),  or  muscular  rheumatism.  It  must  be 
owned  that  the  severer  forms  of  this  affection  can  scarcely  be 
distinguished  from  true  intercostal  neuralgia  by  anything  in 
the  character  or  situation  of  the  pains.  It  will  be  seen,  here- 
after, however,  that  myalgia  has  its  own  specific  history, 
which  is  very  characteristic  ;  at  present,  it  is  sufficient  to  re- 
member that  it  is  often  extremely  like  neuralgia  when  situated 
in  the  dorso-intercostal  region. 

Dorso-intercostal  neuralgia  is  an  affection  of  certain  of  the 
dorsal  nerves.  Tliese  nerv^es  divide,  immediately  after  their 
emergence  from  the  intervertebral  foramina,  into  an  intez'ior 
and  a  posterior  branch.  The  latter  sends  filaments  which  pierce 
the  muscles  to  be  distributed  to  the  skin  of  the  back;  the 
former,  which  are  the  intercostal  nerves,  follow  the  intercostal 
spaces.  Immediately  after  their  commencement  they  commu- 
nicate with  the  corresponding  ganglia  of  the  sympathetic. 
Proceeding  outward,  they  at  first  lie  between  two  layers  of  in- 
tercostal muscles,  and,  after  giving  off  branches  to  the  latter, 
give  off  their  large  superficial  branch.  In  the  case  of  the  sev- 
enth, eighth  and  ninth  intei'costal  nerves,  which  are  those  most 
lia,ble  to  intercostal  neuralgia,  the  superficial  branch  is  given  off 
about  midway  between  the  spine  and  tbe  sternum.  The  final 
point  of  division,  at  which  superficial  filets  come  off,  in  all  the 
eight  lower  intercostal  nerves,  is  nearer  to  the  sternum;  and  is 
progressively  nearer  to  the  latter  in  each  successive  space 
downward.  There  are  thus,  as  Valleix  observes,  three  points 
of  division:  (1)  At  the  intervertebral  foramen  ;  (2)  midway  in 
the  intercostal  space ;  (3)  near  to  the  sternum.  And  there  are 
three  sets  of  branches  (reckoning  the  posterior  division)  which 
respectively  make  their  way  to  the  surface  near  to  these  points. 
In  one  of  its  forms,  intercostal  neuralgia  is  one  of  the  com- 
monest of  all  neuralgic  affections.  I  refer  to  the  jDain  beneath 
the  left  mamma,  which  women  with  neuralgic  tendencies  so 
often  experience,  chiefly  in  consequence  of  over-suckling,  but 
also  from  exhaustion  caused  by  menorrhagia  or  leucorrhoea,  and 
especially  from  the  concurrence  of  one  of  the  latter  affections 
with  excessive  lactation.  It  is  especially  necessary,  however, 
to  guard  against  mistaking  for  this  affection  a  mere  myalgic 
state  of  the  intercostal  or  pectoral  muscles,  which  often  arises 


38  ON  NEURALGIA. 

in  similar  circumstances  with  the  addition  of_  excessive  or  too 
long-  continued  exertions  of  these  muscles.  "Hj'steric"  tender- 
ness also  sometimes  bears  a  considerable  resemblance,  superfic- 
ially, to  true  intercostal  neuralgia,  in  cases  where  the  genuine 
disease  does  not  exist. 

A  less  common  but  very  remarkable  variety  of  intercostal 
neuralgia  than  that  just  mentioned,  is  the  kind  of  ijaiu  which  at- 
tends a  good  many  cases  of  herpes  zoster,  or  shingles.  It  is 
only  of  recent  years  that  any  essential  connection  between  zos- 
ter and  neuralgia  has  been  suspected.  The  occurrence  of  neu- 
ralgia as  a  sequel  to  zoster  had  indeed  been  mentioned  by 
Eayer,  Eecamier,  and  Piorry,  but  the  essential  nature  of  the 
connection  between  the  two  diseases  was  evidently  not  sus- 
pected by  Lecadre,  when,  as  late  as  1855,  he  published  his  val- 
uable essay  on  intercostal  neuralgia.  M.  Notta  was  one  of  the 
first  to  present  connected  observations  on  the  subject.  But  it 
was  much  more  fully  discussed  in  a  paper  published  by  M.  Ba- 
rensprung,  in  1861.  [Ann.  der  Charite-Krakenhauser  zer  Ber- 
lin, ix.,  2,  p.  40.  Brit,  and  For.  Med. Rev.,  January,  1862.]  This 
author  showed  the  absolute  universality  with  which  unilateral 
herpes,  wherever  developed,  closely  followed  the  course  of  some 
superficial  sensory  nerve,  and  gave  reasons,  which  will  be  dis- 
cussed hereafter,  for  sui:)ioosirig  that  the  disease  originates  in  the 
ganglia  of  the  posterior  roots,  and  that  the  irritation  spreads 
thence  to  the  posterior  roots  in  the  cord,  causing  reflex  neural- 
gia. We  shall  have  more  to  say  on  this  matter.  Meantime, 
it  seems  to  be  established,  by  multiplied  researches,  that, 
though  unilateral  herpes  may  and  of  len  does  occur  without 
neuralgia,  and  neuralgia  without  herpes,  the  concurrence  of 
the  two  is  due  to  a  mere  extension  of  the  original  disease 
which  is  a  nervous  one. 

In  young  persons,  zoster  is  not  att-ended  with  severe  neu- 
ralgia, but  a  curious  half-paretic  condition  of  the  skin,  in 
which  numbness  is  mixed  v.dth  formication,  or  with  a  sensation 
as  of  boiling  water  under  the  skin,  precedes  the  outbreak  of  the 
eruption  by  some  hours,  or  by  a  day  or  two.  Painless  herpes 
is  commonest  in  youth.  I  remember,  for  instance,  that,  in  an 
attack  of  shingles  which  I  suffered  about  the  age  of  eleven, 
there  was  at  no  stage  any  acute  pain ;  only,  in  the  pre-eruptive 
period,  for  a  short  time,  I  had  the  curious  sensations  referred 
to  above:  and  the  same  thing  has  occurred  in  all  the  patients 
below  puberty  that  I  have  seen,  if  they  complained  at  all.  From 
the  age  of  puberty  to  the  end  of  life,  the  tendency  of  herpes  to 
be  complicated  with  neuralgia  becomes  progressively  stronger. 
The  course  of  events  varies  much  in  different  cases,  however . 
In  adult  and  later  life  the  symptoms  usually  commence  with  a 
more  or  less  violent  attack  of  neuralgic  pain,  which  is  suc- 
ceeded, and  generally,  though  not  always,  displaced  by  the 
herpetic  eruption.     The  latter  runs  its  course,  and  after  its  dis 


ON  NEURALGIA.  3& 

appearance  the  neuralgia  may  return,  or  not.  In  old  people  it 
almost  always  does  return,  and  often  with  distressing  severity 
and  pertinacity.  Six  weeks  or  two  months  is  a  very  common 
period  for  it  to  last,  and  in  some  aged  persons  it  has  been  known 
to  fix  itself  permanently,  and  cease  only  with  life.  In  these 
subjects  a  further  complication  sometimes  occurs.  The  her- 
petic vesicles  leave  obstinate  and  painful  ulcers  behind  them, 
which  i-efuse  to  heal,  and  which  worry  the  patient  frightfully, 
the  merest  breath  of  air  ujjon  them  sufficing  to  produce  agon- 
izing darts  of  neuralgic  pain .  I  have  known  one  patient,  a 
woman  over  seventy  years  of  age,  absolutely  killed  by  the  ex- 
haustion produced  by  protracted  suffering  of  this  kind. 

The  foci  of  pain  in  intercostal  neuralgia  are  always  found  in 
one  or  more  of  the  points,  already  enumerated,  at  which  sensory 
nerves  become  superficial.  In  long-standing  cases  acutely 
tender  points  are  developed  in  one  or  more  of  these  situations  ; 
not  unfrequently  the  most  decided  of  these  spots  is  where  it 
gets  overlooked,  namely,  opposite  the  intervertebral  foramen. 
H.  G. ,  a  young  woman  aged  twenty-six,  who  applied  to  me  at 
Westminster  Hospital,  had  suffered  for  twelve  months  from  an 
irregularly  intermitting  but  very  severe  neuralgia  at  the  level 
of  the  seventh  intercostal  space  of  the  left  side .  The  violence 
of  the  pain  was  sometimes  excessive,  and  when  the  paroxysm 
lasted  longer  than  usual  it  generally  produced  faintness  and 
vomiting.  This  patient  had  no  sign  of  tenderness  anj^where 
in  the  anterior  or  lateral  regions,  though  the  pain  seemed  to 
gird  round  the  left  half  of  the  chest  as  with  an  iron  chain,  but 
an  exq^^isitely  tender  spot,  as  large  as  a  shilling,  was  found 
close  to  the  spine ;  pressure  on  this  always  induced  a  strong 
feelmg  of  nausea. 

As  an  illustration  of  the  herpetic  variety  of  dorso-intercostal 
neuralgia,  running  a  severe  but  not  protracted  course,  I  may 
relate  the  case  of  a  medical  man  whom  I  formerly  attended. 
This  gentleman  was  about  thirty-two  years  of  age,  and  a  highly 
neurotic  subject:  inter  alia,  he  had  already  suffered  from  a 
severe  and  protracted  sciatica ;  and,  very  shortly  before  the 
herpetic  attack,  had  been  jaundiced  from  purely  nervous 
causes.  His  nervous  maladies  were  undoubtedly  caused  by 
over-brain-work.  In  this  case  the  neuralgia  developed  itself 
during  the  latter  half  of  the  eruptive  period,  T\'hich  was  rather 
unusually  lengthened.  It  occupied  the  seventh,  eighth,  and 
ninth  intercostal  spaces  of  the  side  affected  with  herpes,  and 
was  very  violent  and  acute,  so  that  the  patient  expressed  him- 
self as  almost  "cut  in  two"  with  it.  The  pain  ceased  even 
before  the  vesicles  had  perfectly  heated ;  a  rather  unusiial  oc- 
currence in  my  experience.  I  shall  refer  to  this  case  hereafter, 
as  an  example  of  what  I  believe  to  be  the  effect  of  a  particular 
method  of  treatment  in  lessening  the  tendency  to  after-neural- 
gia .     The  result  of  my  experience  is  certainly  this — that  if  a 


40  ON  NEURALGIA. 

case  of  herpes  in  an  adult,  or  still  more  in  an  aged  person,  be 
left  to  itself,  the  amount  of  af ter-neuralg"ia  will  very  closely 
correspond  with  the  severity  of  the  eruptive  symptoms . 

There  is  a  variety  of  intercostal  neuralgia  which  is  of  more 
importance  than  the  commoner  kinds.  Occurring  mostly  in 
persons  who  have  passed  the  middle  age.  it  possesses  the  char- 
acters of  obstinacy  and  severity  which  belong  to  the  neuralgias 
of  the  period  of  bodily  decay.  It  is  at  first  unattended  with 
any  special  cardiac  disturbance.  By-and-by,  however,  it  begins 
to  attract  more  careful  attention  from  the  fact  that  the  severer 
paroxysms  extend  into  the  nerves  of  the  brachial  plexus  of  the 
affected  side,  so  that  pain  is  felt  down  the  arm.  In  the  mid^t 
of  a  paroxysm  of  intercostal  and  l^rachial  pain,  it  may  happen 
that  the  patient  is  suddenly  seized  with  an  inex]n'essibie  and 
deadly  feeling  of  cardiac  oppression,  and,  in  fact,  the  symptoms 
of  angina  pectoris,  such  as  they  will  be  described  in  a  futuz*e 
chapter,  become  develo]5ed.  A  case  of  this  kind  is  at  present 
under  my  care  at  the  Westminster  Hospital.  The  patient  is  a 
man  only  fifty-six  years  of  age,  but  whose  extreme  intemper- 
ance has  produced  an  amount  of  general  degeneration  of  his 
tissues  such  as  is  randy  seen  except  in  the  very  aged;  he  has 
the  most  rigid  radial  arteries,  and  the  largest  arcus  senilis,  I 
think,  that  I  ever  saw.  This  man  has  long  been  subject  to  at- 
tacks of  ^^olent  intercostal  neuralgia,  and  a  recent  access  as- 
sumed the  type  of  unmistakable  angina.  It  is  very  probable 
that  his  coronary  arteries  have  now  become  involved  in  the  de- 
generative process.  In  this  case,  before  the  development  of 
any  marked  anghial  symiDtoms,  the  paroxysmal  pain,  fi'om 
being  merely  intercostal,  had  come  to  extend  itself  into  the  left 
shoulder  and  arm. 

Intercostal  neuralgia  not  unfrequently  accompanies,  and  is 
sometimes  a  valua.ble  indication  of,  phthisis.  I  do  not  mean  to 
say  that  the  vague  pains  in  the  chest- walls,  which  are  so  very 
common  m  phtliisis,  are  to  be  indiscriminately  accounted  neu- 
ralgia ;  on  the  contrary,  they  are,  in  the  large  majority  of  in- 
stances, merely  myalgic,  and  arise  from  the  participation  of  the 
pectorals,  or  intercostals,  or  both,  in  the  mal-nutrition  which 
prevails  in  the  organism  generally.  But  it  liappens,  sometimes 
that  a  distinctly  intermitting  neuralgia  occurs  as  an  early  s^inp- 
tom  of  phthisis  ;  in  fact,  where  there  is  a  jjredisposition  to  neu- 
rotic affections,  I  believe  that  this  is  not  very  uncommon.  Tiie 
subjects  are  generally  women  ;  they  are  mostly  of  that  class  of 
phthisical  patients  who  have  a  quick  intelligence,  fine  soft  hair, 
and  a  sanguine  temperament.  I  have  had  one  male  patient  un- 
der my  care :  this  was  a  young  gentleman  aged  eighteen,  in 
whon'i  a  neuralgic  access  came  on  with  so  much  severity,  and 
caused  so  much  constitutional  disturbance,  that  the  idea  of 
pleurisy  was  strongly  suggested.  The  paroxysms  retui-ned  at 
irregular  intervals  for  a  considerable  jDariod :    they  were  quite 


ON  NEURALGIA.  41 

unlike  myalgic  i^ains,  not  only  in  their  character,  but  more  es- 
pecially with  respect  to  the  circumstances  which  were  found  to 
provoke  their  recurrence.  They  were  the  first  symptoms 
which  lead  to  any  careful  examination  of  the  chest;  it  was 
then  found  that  there  were  prolonged  expiration  and  slight  dul- 
ness,  at  one  apex.  At  this  period,  wasting  had  not  seriously- 
commenced  ;  but,  on  the  other  hand,  there  was  an  extraordi- 
nary degree  of  debility  for  so  early  a  stage  of  phthisis.  I  am 
inclined  to  think  that  self -abuse  was  the  principal  cause  both 
of  the  phthisis  and  the  neuralgia,  acting  do  ibtless  on  a  predis- 
posed organism,  for  his  family  was  rather  specially  beset  with 
tendencies  to  consumption.  I  may  add  here,  that  it  has  ap- 
peared to  me  that  young  persons  with  i^hthisical  tendencies  are 
si^ecially  liable  to  neuralgic  affections  as  a  consequence  of  self- 
abuse. 

A  special  variety  of  intercostal  neui'algia  is  that  which  at- 
tacks the  female  breast.  The  nerves  of  the  mammae  ai^e  the 
anterior  and  middle  cutaneous  branches  of  the  intercostals ; 
and  they  are  not  unfrequently  affected  with  neuralgia,  which 
is  sometimes  very  severe  and  intractable.  Dr.  Inman  has  very 
properly  pohated  out  that  a  large  number  of  the  cases  of  so- 
called  "  hysterical  breast  "  are  really  myalgic,  and  are  directly 
traceable  to  the  specific  causes  of  myalgia;  but  there  is  no 
question  in  my  mind  that  true  neuralgia  of  the  breast  does 
occur,  and  indeed  is  frequent,  relatively  to  the  frequency  of 
neuralgias  generally.  There  are  several  kinds  of  circumstances 
under  which  it  is  apt  to  occur.  In  highly -neurotic  patients  it 
may  come  on  with  the  first  development  of  the  breasts  at 
puberty ;  and  it  may  be  added  that  this  is  especially  apt  to 
occur  where  puberty  has  been  previously  induced  by  the  un- 
fortunate and  mischievous  influences  to  which  we  had  occasion 
to  refer  in  speaking  of  certain  other  neuralgic©.  A  neuralgia 
of  the  left  breast  occurred  in  a  patient  of  mine,  who  attended 
the  Westminster  Ho!5j)ital.  She  vv^as  only  twelve  years  of  age, 
and  small  of  stature,  but  the  mammae  were  considerably  de- 
velox^ed.  The  face  was  haggard,  there  was  an  almost  choreic 
fidgetiness  about  the  child,  and  a  very  unprepossessing  expres- 
sion of  countenance ;  the  result  of  inquiries  left  no  doubt  that 
the  patient  was  much  addicted  to  self -abuse;  and  it  seemed 
probable  that  to  this  was  due  the  fact  that  menstruation  had 
come  on,  and  was  actually,  menorrhagic  in  amount. 

A  very  painful  kind  of  mammary  neuralgia  is  experienced 
by  some  women  during  jiregnancy ;  but  more  commonly  the 
mammary  pains  felt  at  this  period  are  mere  throbbings,  not 
markedly  intermittent  in  character,  and  j)lainly  dependent  on 
mechanical  distention  of  the  breast:  such  affections  are  not  to 
be  reckoned  among  true  neuralgiae.  A  true  neuralgia  of  a 
very  severe  character  is  sometimes  provoked  by  the  irritation 
of  cracked  nipples.     I  have  seen  a  delicate  lady,  of  highly- 


42  ■      ON  NEURALGIA. 

neurotic  temperament,  and  liable  to  facial  neuralgia,  most  vio- 
lently affected  in  this  way.  Vain  attempts  had  been  made  for 
several  consecutive  days  to  suckle  the  infant  from  the  chapped 
breast ;  when  suddenly  the  most  severe  dorso-intercostal  neu- 
ralgia set  in.  The  attacks  lasted  only  a  few  seconds  each,  but 
they  recurred  almost  regularly  every  hour,  and  were  attended 
with  intense  prostration,  and  sometimes  with  vomiting.  Dis- 
continuance of.  suckling  was  found  necessary,  for  even  the 
application  of  the  child  to  the  sound  breast  now  sufficed  to 
arouse  a  paroxysm  of  pain.  Complete  rest,  protection  of  the 
breast  from  air  and  friction,  and  the  hypodermic  injection  of 
morphia,  rapidly  relieved  the  sufferer. 

(e)  Dorso-luinbar  Neuralgia. — The  superficial  bi^anches  of 
the  spinal  nerves  emanatmg  from  the  lumbar  plexus  are  con- 
siderably less  liable  to  be  affected  with  severe  and  well- 
marked  neuralgia  than  are  the  dorso-intercostal  nerves.  Pains 
in  the  abdominal  walls,  which  are  a  good  deal  like  neuralgia, 
are  not  uncommon ;  but  the  majority  of  them  "will  be  found, 
on  careful  observation,  to  be  myalgia.  At  least,  this  has  been 
the  case  in  my  own  experience. 

When  true  neuralgia  of  the  superficial  branches  of  the 
lumbo-abdominal  nerves  occurs,  it  develops  itself  in  one  or 
more  of  the  following  foci :  (1)  Vertebral  points,  correspond- 
ing to  the  posterior  branches  of  the  respective  nerves :  (2)  an 
iliac  point,  about  the  middle  of  the  crista  ilii ;  (3)  an  abdominal 
point,  in  the  hypogastric  region ;  (4)  an  inguinal  point,  in  the 
groin,  near  the  issue  of  the  spermatic  cord,  whence  the  pain 
radiates  along  the  latter ;  (5)  a  scrotal  or  labial  point,  situated 
in  the  scrotum  or  in  the  labium  majus. 

Such  is  the  description  given  by  Valleix ;  for  rny  own  part, 
I  cannot  say  that  I  have  seen  enough  cases  to  test  its  accuracy. 
I  believe  it  to  be  generally  correct,  yet  it  may  f  anly  be  doubted 
whether  the  author  might  not  have  revised  his  description  had 
the  natural  history  of  myalgic  affections  been  as  carefully  in- 
vestigated as  it  has  since  been.  The  hyiDogastric  foci  of  pain  of 
which  he  speaks  are  at  least  open  to  considerable  suspicion,  as 
it  will  be  shown,  in  the  chapter  on  Myalgia,  that  an  extremely 
common  variety  of  the  latter  affection  is  situated  m  this  re- 
gion, and  the  severity  of  the  pain  which  it  often  produces  might 
well  cause  it  to  be  mistaken  for  a  genuine  neuralgia. 

I  have,  however,  seen  three  or  four  cases  in  which  the  very 
complete  intermittence  of  the  paroxysms,  without  any  per- 
ceptible relation  to  the  question  of  muscular  fatigue,  left  no 
doubt  in  my  mind  of  the  "really  neuralgic  character  of  the 
malady.  In  one  of  these  mstances,  oddly  enough,  the  excit- 
ing cause  appeared  to  be  fright ;  and  this  was  as  severe  a  case 
as  one  often  sees.  The  patient  was  a  woman  of  middle  ago, 
and  mucla  depressed  by  the  long  continuance  of  a  profuse  leu- 
corrhoea.    As  she  was  walking  along  the  street,  a  hei'd  of 


ON  NEURALGIA.  43 

cattle,  in  a  somewhat  irritable  and  disorderly  condition,  came 
suddenly  toward  her ;  she  immediately  began  to  suffer  j)ain 
just  above  the  crest  of  the  ilium,  and  at  the  lumber  region,  and, 
most  acutely,  in  the  labium  majus  of  one  side ;  and  then  pain 
returned  daily,  about  10  a.  m.,  lasting  for  half  an  hour  with 
great  severity.  This  woman's  family  history  was  remark- 
able :  her  mother  had  been  paraplegic,  her  sister  was  a  con- 
firmed epileptic,  and  two  of  her  children  had  suffered  from 
chorea. 

In  two  other  cases  of  lumbo-abdominal  neuralgia  which  were 
under  my  care,  there  were  also  very  painful  points  in  the  sper- 
matic cord  and  in  the  testicle.  One  of  these  cases  will  be  re- 
ferred to  under  the  head  of  Visceral  Neuralgia.  Anotlier  case, 
in  which  severe  quasi-neuralgic  pain  was  referred  to  the 
groin,  will  be  described  in  the  chapter  on  the  Pains  of  Hypo- 
chondriasis. 

(/)  Crural  Neuralgia. — This  appears  to  be  rare  as  an  inde- 
pendent affection  occurring  primarily  in  the  crural  nerve. 
Valleix  had  only  seen  it  twice  in  all  his  large  experience,  and 
I  have  never  seen  it  myself.  Neuralgic  pain  of  the  crural 
nerve  is  almost  always  a  secondary  affection  arising  in  the 
course  of  a  neuralgia,  which  first  shows  itself  in  the  external 
pudic  branch  of  the  sacral  plexus ;  or  else  occurring  as  a  com- 
plication of  sciatica.  A  remarkably  severe  example  of  the  lat- 
ter occurrence  was  observed  in  an  old  man  who  still  occasion- 
ally attends  the  Westminster  Hospital.  He  has  been  a  martyr 
to  the  most  inveterate  bilateral  sciatica  for  between  two  and 
three  years;  and,  within  the  last  three  months,  it  has  extended 
itself  into  the  cutaneous  branches  of  the  curval  nerves  of  both 
thighs.  So  great  an  aggravation  of  the  pain  is  produced  by 
any  muscular  movement,  that  the  patient  can  only  walk  at  the 
slowest  possible  pace,  moving  each  foot  forward  only  a  few 
inches  at  a  time.  The  bilateral  distribution  of  the  pain  is  re- 
markable in  this  case ;  but  there  can  be  no  doubt  of  its  really 
neuralgic  character,  from  the  truly  intermittent  way  in  which 
it  recurs,  and  the  absence  of  any  history  whatever  to  point  in 
the  direction  of  rheumatism,  gout,  or  syphilis. 

The  nervous  supply  to  the  skin  of  the  anterior  and  external 
portion  of  the  thigh  includes  :  (1)  The  middle  cutaneous,  (2) 
the  internal  cutaneous,  and  (3)  the  long  saphenous  branch  of 
the  anterior  crural  nerve  ;  (4)  the  cutaneous  branch  of  the 
obturator ;  and  (5)  the  external  cutaneous  nerve,  derived  from 
the  loop  formed  between  the  second  and  third  lumbar  nerve. 
The  sensitive  twigs  derived  f  rem  the  two  latter  sources,  equally 
with  the  branches  of  the  anterior  crural,  are  liable  to  be  sec- 
ondarily affected  by  neuralgia,  which  commences  in  the  lumbo- 
abdominal  nerves  ;  but  it  must  be  a  rare  event  for  them  to  be 
the  seat  of  a  primary  neuralgia.  The  only  occasion  on  which 
I  have  seen  anything  which  looked  like  the  latter  was  in  the 


44  ON  NEURALGIA. 

case  of  a  porter,  who,  in  straining-  to  lift  a  very  heavy  load, 
ruptured  some  part  of  the  attachment  of  the  tensor  vaginas 
f emoris.  But  the  susceptibility  of  all  the  nerves  of  the  front  of 
the  thigh  to  secondary  or  reflex  neuralgia  receives  numerous 
illustrations.  The  extremely  severe  pain  at  the  internal  aspect 
of  the  knee-joint,  which  is  such  a  common  symptom  in  morbus 
coxas,  is  evidently  a  reflex  neuralgi  i  of  the  long  saphenous 
nerve,  the  ultimate  irritation  being  situated  in  the  branches  of 
the  obturator  nerve  which  supply  the  hip-joints.  For  some 
reason  unexplained,  it  happens  that  this  saijhenous  nerve  is 
specially  liable  to  be  affected  in  a  reflex  manner :  for  instance, 
this  ha^Dpens  in  a  considerable  number  of  cases  of  sciatica,  I 
have  a  lady  now  under  my  observation,  in  whom  the  second- 
ary neuralgia  of  the  saphenous  nerve  has  become  even  more 
intolerable  than  the  pain  in  the  sciatic,  which  was  the  nerve 
primarily  affected.  The  pain  in  these  cases  very  frequently 
runs  down  the  inner  and  anterior  surface  of  the  leg  to  the 
internal  ankle.  Soinetmies  the  branches  of  the  anterior  crural 
become  the  seat  of  intensely  painful  points  in  the  course  of  a 
long-persisting  sciatica.  A  patient  at  present  under  my  care 
has  a  spot,  about  the  size  of  a  shilling,  just  at  the  emergence 
of  the  middle  cutaneous  branch  from  the  fascia  lata,  which  is 
intensely  and  persistently  tender  to  the  touch,  and  the  skin 
here  is  so  exquisitely  sensitive  to  the  continuous  galvanic  cur- 
rent that  the  application  of  moistened  sponge-conductors,  with 
a  current  of  only  fifteen  Daniell's  cells,  causes  intolerable 
burning  pain ;  whereas  at  every  other  part  of  the  limb  the  cur- 
rent from  twenty-five  cells  can  be  borne  without  much  mcon- 
venience. 

(g)  Femoro-popliteal  Neuralgia,  or  Sciatica, — ^Tliis  is  one  of 
the  most  numerous  and  important  groups  of  neuralgia ;  bixt, 
notwithstanding  that  there  are  plenty  of  opportunities  for 
studying  it,  I  venture  to  think  it  is  very  commonly  mistaken 
for  different  and  non-neuralgic  diseases,  and  they  for  it.  The 
rules  of  diagnosis  which  will  be  laid  down  for  all  the  neural- 
giae  would  nevertheless  prevent  these  errors,  if  carefully  at- 
tended to. 

Sciatica  is  a  disease  from  which  j^outh  is  comparatively  ex- 
empt. Valleix  had  collected  one  hundred  and  twenty-four 
cases,  and  in  not  one  was  the  patient  below  the  age  of  seven- 
teen, only  four  were  below  twenty.  In  the  next  decade  there 
were  twenty-two ;  in  the  next,  thirty ;  and  the  largest  number 
of  cases,  thirty-five,  occurred  between  the  ages  of  forty  and 
fifty.  Tliis  completely  tallies  with  my  own  experience,  and 
appears  to  afford  some  supi^ort  to  a  suspicion  I  have  formed, 
that  the  chief  exciting  cause  of  sciatica  is  the  pressure  exercised 
on  the  nerve  in  locomotion,  and  that  tliis  cause  exercises  its 
maximum  influence  when  the  period  of  bodily  degeneration 
commences.     It  is  further  remarkable  that,  in  elderly  persons 


ON  NEURALGIA.  45 

(whose  habits  of  locomotion  are  of  course  more  limited),  the 
proportion  of  fresh  cases  rapidly  diminishes ;  and  also  that 
above  the  age  of  thirty  the  number  of  male  patients  greatly 
exceeds  that  of  female  patients  attacked.  All  this  seems  to 
point  in  the  same  direction. 

According  to  my  observation,  there  are  three  distinct  varie- 
ties of  sciatica.  The  first  of  these  is  obscure  in  its  origin,  but 
may  be  said,  in  general  terms,  to  be  connected  with  a  nervous 
temperament  of  the  highly  impressible  kind,  which  is  more  or 
less  like  what  we  call  "  hysteric,"  not  only  in  the  female,  but 
also  in  male  patients.  The  subjects  of  this  kind  of  sciatica  are 
mostly  young  persons,  and  hardly  ever  more  than  middle- 
aged;  they  are  generally  found  to  be  liable  to  other  forms  of 
neuralgia;  and  the  actual  attack  of  sciatica  is  produced  by 
some  fatigue  or  mental  distress,  which  at  other  times  might 
iiave  brought  on  sick  headache,  or  infracostal  neuralgia,  etc. 
Very  many  of  these  patients  are  anaemic ;  and  chlorotic  anae- 
mia"seems  specially  to  favor  the  occurrence  of  the  affection. 
The  greater  number  of  the  victims  are  females,  and  in  very 
many,  whether  as  cause  or  effect,  there  is  impeded,  or  at  least 
imperfect,  menstruation.  This  kind  of  sciatic  pain  is  not  usu- 
ally of  the  highest  degree  of  iniensity,  but  it  generally  spreads 
into  a  great  many  branches,  both  in  a  direct  and  a  reflex  man- 
ner. It  is  probable  that  this  variety  of  the  disease  is,  at  least 
very  often,  dependent  upon,  or  much  aggravated  by,  an  ex- 
cited condition  of  the  sexual  organs ;  certainly,  I  have  observed 
it  with  special  frequency  in  women  who  have  remained  single 
long  after  the  marriageable  age,  and  in  several  male  joatients 
there  has  been  either  the  certainty  or  a  strong  suspicion  of 
venereal  excess.  Sciatica  of  this  kind  also  occurred  in  the  case 
of  a  single  woman  aged  about  thirty,  who  to  my  knowledge 
was  excessively  addicted  to  self-abuse. 

The  second  variety  of  sciatica  occurs  for  the  most  part  in 
middle-aged  or  old  persons  who  have  long  been  subject  to  ex- 
cessive muscular  exertion,  or  have  been  much  exposed  to  damp 
and  cold,  or  who  have  been  subject  to  the  combined  influence 
of  both  these  kinds  of  evil  influence.  One  must  also  include, 
I  think,  in  this  group  a  considerable  number  of  cases  where  the 
age  is  not  so  advanced,  but  the  patient  has  been  obliged,  by 
the  nature  of  his  business,  to  maintain  the  sitting  posture  daily, 
for  hours  together,  exercising  pressure  on  the  nerve ;  this  is 
especially  liable  to  happen  in  these  persons. 

The  sufferers  from  this  variety  of  sciatica  are  mostly,  as  al- 
ready said,  of  middle  age  or  more ;  biit  this  statement  must  be 
understood  to  be  made  in  the  comparative  sense,  which  refers 
rather  to  the  vital  status  of  the  individual  than  to  the  mere 
lapse  of  years.  Many  of  these  people  have  hair  which  is  pre- 
maturely gray,  and  in  some  the  existence  of  rigid  arteries,  to- 
gether with  arcus  senilis,  completes  the  picture  of  organic  invo' 


46  ON  NEURALGIA. 

lution,  or  senile  degeneration.  In  particular  cases,  where 
depressing-  influences  have  been  at  work  for  a  long  time,  or 
unusuall}'  active,  these  appearances  rectify  the  false  impression 
we  should  otherwise  derive  from  learning  the  mere  nominal 
age  of  the  person ;  this  is  especially  often  the  case  with  regard 
to  patients  who  have  for  a  long  time  drunk  to  excess.  The 
prematurely  and  permanently  gray  hah  (it  will  be  seen  here- 
after that  permanency  of  grayness  is  an  important  point),  to- 
gether with  well-marked  inelasticity  of  artex'ies,  ver}^  often 
tells  a  tale  which  is  most  useful  in  informing  us,  not  only  of 
the  vital  status  of  the  patient,  but  of  the  kind  of  sciatica  under 
which  he  labors ;  and  also  influences  our  prognosis  seriously. 
There  is  otherwise  a  somewhat  deceptive  air  about  the  appeai*- 
ance  of  many  of  these  degenerative  cases ;  for  instance,  a  ruddy 
complexion  is  not  uncommon,  nor  the  retention  of  considera- 
ble, or  even  great,  muscular  strength.  It  is  probable  that  these 
appearances  deceived  Valleix  and  many  others,  or  they  could 
hardly  have  failed,  as  they  have,  to  observe  the  frequency  of 
the  degenerative  type  among  the  most  numerous  group  of  sci- 
atic patients,  namely,  those  between  thirty  and  fifty  years  of 
age.  These  persons  are  not  truly  "robust,"  although  at  a 
hasty  glance  they  might  at  first  seem  to  be  so.  It  would  be  a 
serious  mistake  to  omit  the  search  for  the  important  vital  evi- 
dences which  have  been  referred  to,  since  these  therapeutic 
and  prognostic  indications  are  of  the  highest  value. 

A  prominent  feature  in  this  kind  of  sciatica  is  its  gi'eat  obsti- 
nacy and  intractability.  Another,  equally  marked,  is  the  ten- 
dency to  the  development  of  spots  around  the  foci  of  severest 
pain  which  are  intensely  and  permanently  tender,  and  the 
slightest  pressure  on  which  is  sufiicient  to  set  up  acute  pain, 
This  is  a  symptom  much  less  developed,  if  developed  at  all,  in 
the  variety  of  sciatica  which  we  first  discussed.  The  places 
which  are  especially  apt  to  present  this  phenomenon  of  ten- 
derness are  as  follows  :  (1)  A  series,  or  line  of  xx>ints,  repre- 
senting the  cutaneous  emergence  of  the  posterior  branches, 
which  reaches  from  the  lower  end  of  the  sacrum  up  to  the 
crista  ilii  ;  (2)  a  point  opposite  the  emergence  of  the  great  and 
small  sciatic  nerves  from  the  pelvis  ;  (3)  a  point  opposite  the 
eutaneous  emergence  of  the  ascending  branches  of  the  small 
sciatic,  which  run  up  toward  the  crista  ilii;  (4)  several  points 
at  the  posterior  aspect  of  the  thigh,  corresponding  to  the  cuta- 
neous emergence  of  the  filets  of  the  crural  branch ;  (5)  a  fibu- 
lar point,  at  the  head  of  the  fibula,  corresponding  to  the  divis- 
ion of  the  extei^nal  popliteal ;  (6)  an  external  malleolar,  behind 
the  outer  ankle ;  (7)  an  internal  malleolar. 

I  have  ah-eady  mentioned  that  in  sciatica  the  pain  frequently 
spreads  in  a  reflex  manner  to  nerves  which  are  connected,  by 
then  origin  from  the  plexus,  with  the  sciatic.  It  will  be  re- 
membered, also,  that  I  related  cases  in  which  the  formation  of 


ON  NEURALGIA.  47 

tender  points,  in  the  course  of  the  nerves  thus  secondarily  af- 
fected, was  even  more  distinct  and  remarkable  than  anywhere 
in  the  branches  of  the  sciatic  itself. 

Another  circumstance  which  distingnishesthe  form  of  sciat- 
ica which  we  are  now  describing  is,  the  degree  in  which  (above 
all  other  forms  of  neuralgia)  it  involves  paralysis  of  motion. 
[The  subject  of  the  complication  of  neuralgia  will  be  treated 
in  a  general  manner  farther  on ;  but  it  seems  necessary  to  note 
here  the  special  liability  of  sciatic  patients  to  this  and  to  the 
most  material  complications].  By  far  the  largest  part  of  the 
motor  nervous  supply  for  the  whole  lower  limb  passes  through 
the  trunk  of  the  great  sciatic ;  it  might  thefefore  be  naturally 
expected  that  a  strong  att'ection  of  the  sensory  portion  of  the 
nerve  would  produce,  in  a  reflex  manner,  some  powerful  effect 
upon  the  motor  element.  This  effect  is  most  frequently  in  the 
direction  of  paralysis.  Complete  palsy  is  rare,  but  in  a  large 
proportion  of  cases  which  have  lasted  some  time  there  will  be 
found,  independently  of  any  wasting  of  muscles,  a  positive 
and  considerable  loss  of  motor  power.  It  is  of  course  neces- 
sary to  avoid  the  fallacy  which  might  be  produced  by  neglect- 
ing to  obsei've  whether  movement  was  restricted  merely  in 
consequence  of  its  painfulness.  Not  long  since,  I  had  occasion 
to  test  the  electric  sensibility  in  a  case  of  sciatica,  in  which 
there  was  extremely  severe  pain,  affecting  chiefly  the  peroneal 
region  of  the  leg,  and  great  weakness  of  the  leg,  amounting  to 
inability  for  walking.  The  gastrocnemius  could  hardly  be  got  to 
contract  at  all,  when  the  most  powerful  Faradic  current  was  di- 
rected upon  the  nerve  in  the  popliteal  space  of  the  affected  limb, 
though  the  muscle  of  the  sound  side  reacted  with  great  vigor. 

Anaesthesia  is  also  a  common  complication  of  sciatica,  far 
commoner,  I  venture  to  think,  than  it  has  been  represented 
either  by  Valleix,  or  Notta,.  It  is  necessary,  however,  to  be 
explicit  on  this  point.  In  the  early  stages,  both  of  this  form 
of  sciatica,  and  of  the  milder  variety  previously  described, 
there  is  almost  always  partial  numbness  of  the  skin  previous 
to  the  first  outbreak  of  the  neuralgic  pain,  and  during  the  in- 
tervals between  the  attacks.  By  degrees  this  is  exchanged,  in 
the  milder  form,  for  a  generally  diffused  tenderness  around  the 
foci  of  neuralgic  pain,  while  other  portions  of  the  limb  remain 
more  or  less  anaesthetic.  In  the  severer  forms  it  sometimes 
happens  that,  besides  an  intense  tenderness  of  the  skin  over 
the  painful  foci,  there  is  diffused  tenderness  over  the  greater 
part  or  the  whole  of  the  surface  of  the  limb.  But  it  is  impor- 
tant to  remark  that  both  in  the  anaesthetic  and  the  hyperses- 
thetic  conditions  (so  called)  the  tactile  sensibility  is  very  much 
diminished.  I  have  made  a  great  many  examinations  of  pain- 
ful limbs, in  sciatica,  and  have  never  failed  to  find  (with  the 
compass  points)  that  the  power  of  distinctive  perception  was 
decidedly  lowered. 


48  ON  NEURALGIA. 

Convulsive  movements  of  muscles  are  met  with  in  a  moder- 
ate proportion  of  cases  of  sciatica  in  middle  and  advanced  life, 
in  which  affection  they  are  entirely  involuntary.  They  differ 
from  certain  spasmodic  movements  not  unfrequentiy  observed 
in  the  milder  form  (and  especially  in  hysteric  women),  for 
these  are  more  coruiected  with  morbid  volition,  and  are,  in 
truth,  not  perfectly  involuntary.  In  several  cases  of  inveter- 
ate sciatica  I  have  seen  violent  spasmodic  flexures  of  the  leg 
upon  upon  the  thigh.  Cramps  of  i^articular  muscles  are  occa- 
sionally met  with.  I  have  seen  the  flexore  of  the  toes  of  tlic 
affected  limb  violently  cramped,  and  in  one  case  there  was  ago- 
nizing- cramp  of  the  gastrocnemius.  It  is  chiefly  at  night,  and 
especially  when  the  patient  is  fallmg  asleep,  that  this  kind  of 
affection  is  apt  to  occur. 

A  third  variety  of  sciatica  is  the  rather  uncommon  one,  so 
far  as  my  experience  goes,  in  which  inflammation  of  the  tissues 
around  the  nerve  is  the  primary  affection,  and  the  neuralgia  is 
mere  secondary  effect,  from  mechanical  pressure  on  the  nerve, 
which,  however,  is  not  apparently  itself  inflamed.  I  believe 
that  these  cases  are  sometimes  caused  by  syphilis,  and  some- 
times by  rheumatism.  One  of  the  most  violent  attacks  of  sci- 
atic j)ain  which  ever  came  under  my  notice  was  in  a  syphil- 
ized  subject,  a  discharged  soldier,  who  had  been  the  victim  of 
severe  tertiary  affections,  and  had  been  mercilessly  salivated 
into  the  bargain.  This  unfortunate  man  suffered  dreadful  ag- 
ony, which  was  aggravated  every  night,  but  was  never  totally 
absent,  Tlie  pain  started  from  a  point  not  far  behuid  the  great 
trochanter:  pressure  here  caused  intolerable  darts  of  pain, 
which  ramified  into  every  offshoot  of  the  sciatic  nerve,  as  it 
seemed,  and  ma,de  the  man  quite  faint  and  sick.  Large  doses 
of  iodide  of  potassium,  together  with  the  prolonged  use  of  cod- 
liver  oil,  completel}"  removed  the  pain  and  tenderness.  It  need 
hardly  be  said  that  cases  of  this  kind  are  essentially  different, 
and  require  perfectly  different  principles  of  treatment,  from 
neiiralgias  in  which  the  disturbance  originates  within  the  ner- 
vous tissues  themselves. 

The  chronic  rheumatism  does  also,  occasionally,  affect  the 
sheath  of  the  nerve  in  such  a  manner  as  to  produce  a  deposit 
which  sets  up  neuralgic  pam,  must  also  be  admitted,  although  I 
beheve  the  number  of  such  cases  to  be  preposterously  over-esti- 
mated by  careless  observers.  It  has  several  times  happened 
that  a  patient  has  come  under  my  care  Avith  so-called  "rheu- 
matic affection  of  the  nerves  "  of  the  thigh  and  leg,  and  that 
on  examination  one  has  found  all  the  symptoms  and  clinical 
history  of  a  neurosis,  but  not  the  slightest  valid  argument  for 
a  diagnosis  of  the  rheumatic  diathesis.  Indeed,  upon  this 
point,  I  think  it  is  time  that  a  decided  opinion  should  be  ex- 
pressed. I  firmly  believe  that  a  large  number  of  sciatic  pa- 
tients have  their  health  rumed  by  treatment  directed  to  a  sup- 


ON  NEURALGIA.  49 

posed  rheumatic  taint  which  is  purely  imaginary.  The  state 
of  medical  reasoning,  suggested  by  the  way  in  which  too  many 
practitioners  decide  that  such  and  svich  pains  are  rheumatic  in 
their  origin,  is  a  melancholy  subject  for  reflection.  Nearly  al- 
ways it  will  be  found,  on  cross-exammatioH,  that  the  state  of 
the  urine  has  been  made  the  basis  of  a  confident  diagnosis ;  the 
practitioner  will  tell  you  that  the  urine  was  loaded,  z,  e. ,  with 
lithtaes.  He  ignores  the  fact  that  nothing  is  more  connnon,  in 
neurotic  patients  who  are  perfectly  guiltless  of  rheumatic  pro- 
pensities, than  a  fluctuation  between  lithiasis  and  oxaluria, 
neither  of  which  phenomena,  under  the  circumstances,  indi- 
cates any  more  than  a  temporary  defect  of  secondary  assimila- 
tion of  food,  produced  by  nervous  commotion.  I  may  per- 
haps find  room,  on  a  future  page,  for  a  few  further  remarks  on 
the  subject;  at  present  I  only  put  in  a  caution  against  too 
ready  an  acceptance  of  the  rheumatic^  hypothesis. 

II.  Visceral  Neuralgias.- ZJferwe  a 3i(i  Ovarian  Neuralgia. 
This  is  an  important  group  of  neuralgic  affections,  and  one  which 
I  cannot  help  thinking  is  strangely  misappreciated,  very  often, 
in  a  therapeutic  point  of  view.  In  one  aspect  these  aiTections 
possess  a  special  interest,  namely  this,  that  they  are  more  fre- 
quently dependent  on  i^eripherai  irritation  for  their  immediate 
causation  than  any  other  group  of  neuralgias.  If  we  consider 
the  great  copiousness  of  the  nervous  supply  to  the  uterus  and 
ovaries,  and  the  powerfully  disturbing  character  of  the  func- 
tional processes  which  are  periodically  occurring  in  these  or- 
gans, we  shall  be  at  no  loss  to  understand  how  this  may  be. 
The  amount  force  of  the  peripheral  influence  and  which  are 
brought  to  bear  upon  the  central  nervous  system  by  the  func- 
tions of  the  uterus  and  ovaries  are  greater  than  any  that  eman- 
ate from  the  diseases  and  functional  disturbances  of  any  other 
organ  in  the  body. 

The  most  common  variety  of  peri-uterine  neuralgia  is  that 
which  attends  certain  kinds  of  difficult  menstruation.  It 
would  be  liardly  correct  to  give  the  name  of  neuralgia  to  the 
pahi  existing  in  these  very  numerous  cases  of  dysmenorrhoea 
in  which  the  suffering  is  apparently  altogether  dependent  on 
the  mere  retention  or  difficult  escape  of  the  menstrual  fluid, 
althougli  the  character  of  the  pain  often  resembles  the  neural- 
gic type.  There  is  another  group  of  dysmenorrhoeal  affections 
however,  in  which  the  pain  may  fairly  be  called  neuralgic, 
since  it  is  apparently  independent  of  the  circumstances  of  the 
discharge  of  menstrual  fluid,  and  simply  attends  the  i^rocess, 
seemingly  on  account  of  a  naturally-exaggerated  irritability  of 
the  organs  concerned.  There  is  a  large  class  of  young  women 
in  whom,  and  more  especially  before  marriage,  the  time  of 
menstruation  is  always  marked  by  the  occurrence  of  more  or 
less  severe  pain.  Formerly  I  used  to  believe  that  this  pam  was 
relieved  on  the  occurrence  of  the  discharge,  but  I  have  seen  too 
4 


50  ON  NEURALGIA, 

many  cases  of  a  contrary  nature  to  retain  this  opinion.  I  now 
believe  that  the  subjects  of  the  kind  of  menstrual  pain  to  which 
I  am  referring  are  naturally  endowed  with  a  very  irritable  ner- 
vous apparatus  of  the  pelvic  organs,  and  that  there  is  a  certain 
character  at  once  of  immaturity  and  excitability  in  their  sexual 
organs,  especially  in  the  virgin  condition.  So  far  from  these 
females  being  disposed  to  sterility,  as  is  too  often  the  case  with 
those  dysmenorrhoeal  subjects  whose  troubles  depend  upon  oc- 
clusion, distortion,  or  narrowing  of  the  outlets,  they  are  often 
extremely  apt  to  the  generative  function ;  and,  what  is  more, 
the  full  and  natural  exercise  of  the  sexual  function  appears 
necessary  to  the  health  of  their  organs,  as  is  shown  by  the  fact 
that  these  menstrual  pains  lose  their  abnormal  character,  com- 
pletely or  in  great  part,  after  marriage,  and  especially  after 
child-bearing.  The  contrast  between  the  two  types  of  dysmen- 
orrhoeal patients  is  sharply  brought  out  by  the  two  following 
cases : 

Case  I. — S.  M.,  a  housemaid,  aged  twenty-three  when  first 
under  my  notice,  was  the  x^icture  of  physical  health  and 
strength,  very  intelligent,  and  a  girl  of  excellent  character 
and  most  industrious  habits.  At  every  menstrual  period,  how- 
ever, she  suffered,  for  some  hours  previously  to  the  occurrence 
of  the  flow,  from  severe  pain  in  the  uterine  region,  which  was 
tumefied  and  tender.  Hot  hip-baths  gave  some  relief,  appar- 
ently by  hastening  the  discharge ;  as  soon  as  the  latter  was  es- 
tablished, the  pain  rapidly  subsided.  This  young  women  mar- 
ried a  healthy  and  vigorous  young  man,  but  has  never  had  any 
children,  and  at  the  date  of  my  last  inquiries  still  suffered  peri- 
odically from  her  old  troubles. 

Case  II. — Mrs.  B.  was  married  at  the  age  of  twenty-six.  Up 
to  the  date  of  her  marriage  she  used  to  suffer  the  most  severe 
pain  at  every  menstrual  period,  the  pain ;  however,  bore  no  re- 
lation to  the*^ freedom  of  the  discharge,  but  always  lasted  about 
the  same  length  of  time,  under  any  circumstances,  or  was  only 
less  or  more  according  as  the  general  bodily  vigor  was  greater 
or  less  at  the  moment.  From  the  date  of  marriage  these 
troubles  steadily  declined;  a  child  was  born  at  the  end  of 
twelve  months,  and  the  menstrual  troubles  have  never  re- 
sumed a  serious  shape  up  to  the  present  time,  a  period  of  nearly 
nine  years.  -This  lady  is  herself  a  neuralgic  subject,  liable  to 
migraine  in  circumstances  of  fatigue,  and  suffering  horribly 
from  it  during  her  pregnancies ;  and  slae  comes  of  a  family  in 
whom  the  nervous  temperament  is  strongly  develoi^ed. 

It  must  not  always  be  concluded,  because  the  menstrual  pain 
is  very  severe  before  the  discliarge  and  is  I'elieved  at  or  soon 
after  its  appearance,  that  the  case  is  one  of  occlusiop,  and  not 
of  neuralgia.  There  is  a  class  of  cases  in  which  the  affection 
appears  to  be  a  very  severe  ovarian  neuralgia,  attended  with  a 
■e^o'^motO'r  pkralysisAvhich   causes  great  engorgement  of  tha 


ON  NEURALGIA,  51 

ovary  and  consequent  difficult  of  "ovulation."  I  have  seen 
several  instances  which  I  could  not  explain  in  any  othei' 
way. 

Case  III. — One  patient  I  particularly  remember,  from  tne 
fact  that  she  was  always  attacked  with  dreadful  pain,  which 
was  sometimes  seated  in  one  groin  and  sometimes  in  the  other, 
but  was  regularly  attended  with-  large  and  palpable  tumefac- 
tion of  the  ovary,  which  began  to  subside  when  the  discharge 
commenced.  This  woman  married  rather  late,  but  her  men- 
sural troubles  immediately  became  less,  and  she  became  preg- 
nant and  was  happily  delivered,  nearly  as  soon  as  was  possible. 
She,  too,  was  a  decidedly  neuralgic  subject,  independently 
of  her  tendency  to  dysmenorrhoeal  ovarian  pain. 

Insome  women  who  remain  single  long  after  the  marriage- 
able age,  ovarian  or  uterine  neuralgia  becomes  a  constantly- 
recurring  torment,  not  only  at  the  menstrual  period,  but  at 
various  other  times  when  they  are  depressed  or  fatigued  in 
body  or  mind.  As  might  be  expected,  this  tendency  is 
greatly  aggravated  in  the  rarer  cases  where  the  patient's  mind 
dwells  in  a  conscious  manner  on  sexual  matters,  especially  if 
by  an  evil  chance  she  becomes  addicted  to  self -abuse.  Among 
the  many  reproaches  that  have  been  thrown  upon  the  indis- 
criminate use  of  the  speculum  in  examining  unmarried  women, 
it  has  often  been  urged  that  it  tends  to  excite  sexual  feelings. 
I  do  not  for  a  moment  doubt  that  this  is  the  case,  or  that  the 
indiscriminate  use  of  the  instrument  is  altogether  indefensible. 
But  I  expect  that  neuralgic  pain  of  the  uterus  or  ovaries,  in 
unmarried  women,  connected  with  an  already  irritable  condi- 
tion of  the  sexual  organs,  has  often  been  the  reason  why  such 
women  have  applied  for  advice  and  has  consequently  been  ex- 
amined with  the  speculum ;  and  that  the  same  thing  has  fre- 
quently happened  m  the  case  of  women  who  have  been  left 
widows  at  a  time  of  life  when  the  sexual  powers  were  still  in 
full  vigor.     These  patients  deserve  great  pity. 

The  pei-ipheral  irritation  which  gives  rise  to  peri-uterine 
neuralgia  is  not  always  originally  seated  in  the  organs  of  gen- 
eration. The  following  are  various  sources  of  external  irrita- 
tion which  I  have  known  to  produce  the  affection  : 

1.  Ascarides  in  the  rectum  sometimes  produce  pelvic  neural- 
gia. A  woman,  aged  thirty-four,  single,  was  under  my  care  in 
King's  College  Hospital  many  years  ago,  under  suspicions  of 
ulcerated  cervix.  On  examination,  no  lesion  could  be  detected. 
It  was  discovered  that  the  rectum  was  infested  with  ascarides, 
and,  after  the  use  of  appropriate  vermifuges  and  tonics,  the 
patient  entirely  lost  the  uterine  pains  and  also  a  tormenting 
pi-uritus  vaginae,  from  vdiich  she  suffered.  This  woman  had 
at  various  times  suffered  from  neuralgic  headache  a  good  deal. 

2.  Profuse  and  intractable  leucorrhoea,  whether  associated  or 
not  with  ulceration  of  the  cervix,  may  produce   peri-uterino 


52  ■    ON  NEURALGIA. 

neuralgia,  even  of  great  severity,  when  there  are  strongly- 
marked  neurotic  tendencies.  It  must  be  noted,  however,  that 
many  cases  of  pain  in  leucorrhoeal  subjects,  which  superficially 
bear  the  aspect  of  neuralgia,  turn  out  on  closer  investigation 
to  be  merely  examples  of  myalgia  of  the  abdominal  muscles  or 
aponeuroses. 

3.  Calculus  in  the  kidney,  or  in  the  ureter,  sometimes  causes 
intolerable  ovarian  neuralgia.  In  the  case  of  a  woman  who  was 
under  my  care  at  the  Chelsea  Dispensary,  some  years  ago,  this 
was  tlie  unsuspected  origin  of  severe  neuralgic  pains  in  the  left 
ovary,  which  recurred  several  times  a  day,  and  which  certainly 
contributed  to  the  patient's  death  by  the  exhaustion  which  they 
produced.  A  calculus  was  found  tightly  impacted  in  the 
uterer,  near  the  kidney. 

4.  Prolapsus  uteri  sometimes  gives  rise  to  severe  peri-uterine 
neuralgia,  or  what  appears  to  be  such ;  though  it  is  diflBcult 
here  to  draw  the  line  between  neuralgia  and  myalgia.  The 
commonest  kind  of  pains  from  prolajDSus  uteri  are  not  neural- 
gic in  their  nature  at  all,  but  are  of  a  "bearing  down  "  charac- 
ter, and  probably  depend  upon  actual  contractile  movement  of 
the  walls  of  the  uterus. 

6.  The  presence  of  tumors,  either  cancerous  or  fibroid,  in 
the  uterus  or  its  appendages,  gives  rise,  frequently,  to  severe 
aisi  indeed  almost  intolei'able  pains  of  a  distinctly  intermittent 
character.  In  the  eai4y  stages  of  cancerous  diseases  these 
pains  are  usually  felt  at  the  lower  part  of  the  back  ;  in  the 
later  stages  they  are  felt  also  in  the  hypogastric  region,  andai'e 
then  much  more  severe. 

6.  Ulcer  of  the  cervix,  of  a  non-malignant  kind,  probably 
£ff)metimes  gives  rise  to  neuralgic  pain  of  the  uterus,  though 
this  is  not  so  severe  as  in  cancer. 

7.  Large  masses  of  scybalous  faeces,  impacted  in  the  rectum, 
will  occasionally,  by  the  pressure  whiich  they  exert  on  nerves, 
set  up  violent  neuralgia  of  uterus  or  ovaries,  the  true  nature 
of  which  is  accidentally  discovered  by  the  use  of  aperients 
which  unload  the  uitestine  and  put  an  end  to  the  suffering.  No 
doubt  it  is  chiefly  in  persons  with  neuralgic  predisposition  that 
this  effect-  is  produced;  for,  common  as  is  the  occurrence  of 
extreme  constipation  in  women,  it  is  comparatively  very  rare 
for  us  to  hear  of  distinctly  neuralgic  j^ain  being  caused  by  it. 

8.  The  condition  known  as  "ii'ritable  uterus,"  ever  since 
Gooch's  classical  description  of  it,  is  always  attended  with 
uterine  pain,  which  is  continuous,  but  is  liable  to  periodical 
exacerbations  of  great  severity.  In  this  disorder  there  is  no 
recognizable  physical  disease  of  the  pelvic  organs,  and  the  pa- 
tient will  generally  be  found  to  have  suffered  neui*algia  in  other 
parts  of  the  body  on  previous  occasions.  [There  is  some  differ- 
ence of  opinion  about  this  affection  :  some  authors  (e.g.,  Han- 
field  Jones)  considering  it  as  distinct  from  the  true  neuralgias.] 


ON  NEURALGIA.  53 

9.  Eeflex  irritation,  tlie  source  of  wlaicli  is  in  some  quite 
distant  part  of  the  body,  has  in  many  recorded  instances  occa- 
sioned uterine  neuralgia,  in  highly-predisposed  persons.  I 
have  seen  one  case  in  which  severe  pain  of  this  kind  was 
clearly  jjroved  to  have  been  excited  by  the  presence  of  a  carious 
tooth  which  was  itself  little,  if  at  all,  painful,  but  the  removal 
of  which  at  once  cured  the  pelvic  pain . 

Neuralgia  of  the  urethra  is  an  affection  which  is  occasionally 
seen,  both  in  males  and  females.  I  have  observed  it  three 
times  ;  all  these  cases  were  apparently  traceable  to  the  effects 
of  excessive  self-abuse.  The  male  subject  was  an  luimarried 
m.an,  aged  forty-two,  of  cadaverous  appearance,  much  emaci- 
ated, with  clanuny,  perspiring  skin,  and  habitual  coldness  of 
the  extremities  ;  he  suffered  much  from  dyspepsia  and  palpita- 
tion of  the  heart.  The  paui  ran  along  the  under  side  of  the 
penis,  which  was  very  large,  with  an  elongated  prepuce.  The 
paroxysms  were  severe,  and  came  on  chiefly  in  the  morning, 
soon  after  he  awoke.  No  remedies  did  this  man  any  permanent 
good,  and  he  passed  out  of  my  sight,  being  at  that  time  in  a 
condition  of  wretched  febleness,  and  with  symptoms  of  threat- 
ened dementia.  Of  tlie  female  subjects,  one  was  a  married 
woman,  who  accused  her  husband  of  impotence,  and  from  her 
account  it  would  certainly  appear  that  effective  connection  had 
never  taken  place;  the  hymen  was  completely  destroyed, 
however.  The  neuralgic  pains  recurred  nightly  in  several 
paroxysms,  and  Vv^ere  especially  severe  about  the  time  of  the 
monthly  periods.  In  this  case  the  patient  was,  she  stated,  in- 
duced to  give  up  her  malpractices ;  at  any  rate,  the  pain  sub- 
sided in  a  manner  which  could  not  be  Avell  accounted  for  by 
any  direct  influence  of  the  medicinal  treatment.  The  other 
female  patient  was  a  widow  in  whom  the  morbid  habit  was 
suspected  from  her  general  appearance,  and  from  the  existence 
of  enlarged  clitoris  and  other  signs  of  irritation  about  the  ex- 
ternal parts :  she  became  rather  rapidly  phthisical,  and  suffered 
severely  from  neuralgic  headaches . 

Neuralgia  of  the  bladder  has  been  specially  described  by 
various  writers  ;  the  pain  is  usiially  spoken  of  as  seated  at  the 
neck  of  the  bladder,  and  as  accompanied  by  frequent  desire  to 
micturate.  I  have  seen  two  cases,  both  in  women  :  the  first 
was  eventually  discovered  to  be  an  instance  of  malignant  dis- 
ease of  the  fundus  of  the  bladder  ;  the  other  was  apparently 
the  result  of  a  long-continued  menorrhoeal  flux,  which  had 
greatly  impaired  the  health,  and  produced  extreme  anjemia.  In 
neither  of  these  instances  was  the  pain  referred  to  the  external 
meatus,  as  in  the  female  patients  above  mentioned  who  were 
suffering  from  urethral  neuralgia.  I  have  never  seen  the 
extreme  examples  of  vesical  neuralgia  described  by  some 
writers,  in  which  actual  paralysis  of  tbe  coats  of  the  bladder 
was  secondarily  produced;   but  the  reflex  influence  of   the 


54  .  oy  ?:et7Ealgia. 

neuralgic  afiFection  in  both  the  examples  just  mentioned  ap- 
peared to  produce  great  weakening  of  the  muscvdar  power  of 
the  rectum,  occasioning  most  obstinate  and  troublesome  con- 
stipation. 

It  would  appear,  from,  recorded  cases,  that  both  the  bladder 
and  the  uterus  are  liable  to  be  affected  with  neuralgia  from 
malarious  influences  ;  but  I  have  never  chanced  to  see  any 
such  cases. 

Neuralgia  of  the  kidney_  is  spoken  of  by  several  writers, 
and  I  suj)pose  there  there  is  no  doubt  that  it  may  exist  as  a 
si^ecial  neurotic  disease  with  obvious  organic  cause.  For  my 
own  part,  I  cannot  say  that  I  have  ever  seen  it  except  in  in- 
stances where  there  was  either  the  certainty,  or  a  very  strong 
suspicion,  that  the  cause  was  the  mechanical  pressure  and  iiTi- 
tation  of  a  calculus  within  the  kidney.  The  diagnosis  of  the 
simple  functional  disorder  must  be  excessively  perfjlexing  ; 
for  in  the  first  place  there  is  the  greatest  difficulty  m  making 
sure  that  the  pain  is  not  external,  and  seated  either  in  the 
muscles  of  the  back,  or  in  the  superficial  doi^sal  or  lumbar 
nen'es,  and  certainly  I  am  strongly  inclined  to  su.spect  that 
this  has  been  reaUy  the  case  in  many  examples  of  so-called 
renal  neuralgia.  That  neuralgia  of  the  kidney  may  arise 
secondarily,  as  a  reflex  extension  of  jDelvic  neuralgia,  does, 
however,  a^^pear  proljal^le  enough :  for  it  is  almost  certain  that 
in  the  latter  affection  at  least,  the  vaso-motor  nerves  of  the 
kidneys  must  be  strongly  influenced  in  a  reflex  manner:  since 
the  crisis  or  acme  of  a  paroxysm  of  pelvic  pain  is  not  unfre- 
quently  attended  with  a  copious  secretion  of  jDale  urine. 

Keuralgia  of  the  rectum  has  been  carefully  descril>ed  by  ]\Ir. 
Ashton,  but  is  probaljly  not  often  seen  excejit  by  practitioners 
who  possess  special  ojoportimities  of  observing  rectal  diseases. 
In  the  one  pure  case  which  has  fallen  under  my  notice  the 
patient  complahaed  of  acute  paroxysmal  cutting  pains  extend- 
ing about  one  inch  witliin  the  anus,  and,  as  these  were  gi^eatly 
increased  by  defecation  I  suspected  the  existence  of  fissure. 
Nothing  of  the  kind,  however,  was  found  on  examination; 
and  the  pain  ultimately  j'ielded  to  repeated  subcutaneous  in- 
jections of  atrojDme.  This  patient  had  got  wet  through,  and 
had  sat  in  his  damp  clothes,  getting  thoroughly  chilled:  the 
pain  came  on  with  gi'eat  suddenness  and  severity,  and  the  ten- 
derness which  has  been  mentioned  was  developed  very  quickly, 
probably  the  influence  of  coldand  wet  is  among  the  counnon- 
est  causes  of  the  complaint.  Mr.  Ashton  also  reckons  as  causes, 
reflex  irritation  from  other  parts  of  the  alimentary  canal,  and 
the  influence  of  malaria .  He  observes  that  the  subjects  of  the 
affection  are  most  frequently  anarmic.  and  of  a  gererally  ex- 
citable and  dei'anged  susceptibility,  and  that  females,  who,  from 
menorrhagia,  or  frequent  child-bearing  with  much  hcemor- 
rhage,  have  lost  a  great  deal  of  blood,  are  specially  predisposed. 


ON  NEURALGIA.  55 

Neuralgia  of  the  testis  (as  an  independent  affection  and  not 
a  mere  extension  of  lumbo-abdominal.  neuralgia)  is  fortunately 
a  much  less  common  maladj^  than  the  corresponding  affection 
of  tlie  ovary ;  as  might  indeed  be  expected,  from  the  much 
less  degree  of  functional  j)erturbation  to  which,  in  ordinary 
physiological  circumstances,  the  former  organ  is  exposed  than 
the  latter.  Except  from  actual  growths  within  the  testis,  of 
which  it  was  a  mere  symptom,  I  have  never  seen  neuralgia  of 
the  testis  save  from  one  of  three  causes.  In  one  remarkable 
example  it  was  produced  as  a  reflex  effect  of  severe  herpes  pre- 
putialis.  Secondly,  it  is  sometimes  observed  as  a  symptom  of 
calculus  descending  the  ureter.  And,  thirdly,  I  have  seen  it 
several  times  undoubtedly  produced  by  excessive  self  abuse. 

The  occurrence  of  testicular  neuralgia,  in  one  case  of  epil- 
epsy, as  to  the  cause  of  which  I  had  been  previously  much 
puzzled,  led  to  the  discovery  of  the  real  origin  of  the  fits.  I 
should  observe  here  that  I  do  not  believe  that  self -abuse  is 
ever  more  than  an  immedia,tely  exciting  cause  of  epilepsy,  a 
predisposition  to  the  disease  having  previously  existed  in  all 
cases.  In  the  patient  just  referred  to,  there  was  a  family  his- 
tory of  epileiJsy,  but  it  was  difficult  to  explain  the  excitmg 
cause  until  this  was  suggested  by  the  occurrence  of  neuralgic 
pain  in  the  testicle .  Tlie  patient  relinquished  his  habit,  and 
both  the  pain  and  the  epilepsy  ceased,  and,  for  some  twelve 
months  during  which  I  liad  him  under  observation,  had  not 
recurred  at  all .  A  medical  friend  has  informed  me  of  an  in- 
stance in  which  the  same  habit  had  produced  a  neui'algia  of 
the  testis  so  severe  as  to  strongly  tempt  the  patient  to  castrate 
himself,  and  he  would  probably  have  done  so  but  that  he  was 
too  much  of  a  coward  with  regard  to  physical  pain.  The  at- 
tacks of  pain  were  so  severe  as  frequently  to  produce  vomiting 
and  the  greatest  prostration. 

Hepatic  Neuralgia-— lb  mMst  be  allowed  that  the  evidence 
even  for  the  existence  of  neuralgia  of  the  liver  is  at  present  m 
an  unsatisfactory  state .  At  the  same  time,  there  are  carefully- 
recorded  cases,  by  Trousseau  and  other  *  vmters  of  unques- 
tionable authoritj^,  ^vhich  leave  no  doubt  in  my  mind,  corrob- 
orated as  they  are  by  a  certain  amount  of  experience  of  my 
own,  that  such  a  form  of  neuralgia  really  exists .  I  must,  of 
course,  be  understood  to  refer  to  something  altogether  differ- 
ent from  the  spasmodic  pain  which  is  produced  by  the  difficult 
passage  of  a  gall-stone  toward  tlie  bowel.  I  have  now  seen 
several  cases  m  which,  as  it  appeared  to  me,  there  v,"as  suffi- 
cient evidence  of  neuralgic  pain  seated  in  the  liver  itself,  and 
not  dependent  either  on  gall-stone  or  any  so-called  organic 
diseases  of  the  viscus. 

■^Trousseau,  Clinique  Medicale.  Vanlair,  " Des  dieffreutes  Formes 
du  Nevralgies,"  Jouru  de  Med.  de  Bruxelles,  tomexl. 


56  .    ON  NEURALGIA. 

The  subjects  of  liepatalgia  are  probably  never  roubled  only 
by  pain  in  the  liver ;  they  are  persons  of  a  nervous  tempera- 
ment, in  whom  a  slight  shock  to,  or  fatigue  of,  the  nervous 
system,  habitually  provokes  neuralgic  attacks ;  the  pain  local- 
izing itself  sometimes  in  the  branches  of  the  trigeminal,  some- 
times in  those  of  the  sciatic,  sometimes  m  the  intercostal 
nerves,  etc.  In  one  instance  which  has  been  under  my  obser- 
vation, the  attacks  of  liepatalgia  alternated  with  cardiac  neu- 
ralgia assuming  the  type  'of  a  rather  severe  angina  pectoris. 
In  another  case  the  patient,  a  man  aged  sixty-seven,  was  very 
liable  to  attacks  of  intermittent  abdominal  agony,  in  which 
one  could  hardly  doubt  that  the  pain  was  located  in  the  colon, 
and  was  attended  with  paralytic  distention  of  the  bowel ;  the 
peculiar  feature  of  the  case  being  the  sudden  way  in  which 
the  symptoms  would  appear  and  depart,  independently  of  any 
recognizable  provocation  or  the  use  of  any  remedies .  On  two 
separate  occasions  this  patient  Avas  attacked  with  pain  of  a 
precisely  similar  kind,  but  limited  to  the  right  hypochondrium, 
attended  with  great  depression  of  spirits,  and  followed  by  a 
well-pronounced  jaundice.  So  remarkable  was  the  conjunc- 
tion of  symptoms  in  these  tv/o  attacks  that  a  strong  suspicion 
of  biliary  calculus  was  raised,  but  not  the  slightest  coniirma- 
tion  of  this  idea  could  be  obtained ;  and  indeed  one  symptom — 
vomiting — which  nearly  always  attends  the  painful  passage  of 
a  biliary  calculus,  was  altogether  absent . 

Puttmg  aside  a  considerable  number  of  cases  in  which 
"pain  in  the  liver"  was  vaguely  complained  of  by  patients 
who  were  plainly  hypochondriacal,  and  whose  account  of 
their  own  sufferhigs  could  not  be  relied  on,  I  have  altogether 
seen  live  instances  of  v/hat  I  regard  as  genuine  hepatalgia- 
The  first  of  these  was  very  remarkable  in  its  history  and  in  all 
its  features.  The  patient  was  a  respectable  girl  of  eighteen, 
subject  to  migraine,  who  liad^  reason  to  fear  that  she  had  be- 
come iDregnant,  though  this  proved,  ultimately,  not  to  be  the 
case.  Under  these  circumstances  she  was  attacked  with  inter- 
mittent pains,  in  the  right  hypochondrium,  of  intolerable 
severity;  resembling,  in  fact,  the  pain  of  biliary  calculus, 
but  without  the  sense  of  abdominal  constriction,  and 
without  any  vomiting.  These  recurred  daily  at  about  the 
the  same  hour  in  the  morning,  for  about  ten  days;  v/hen 
rather  suddenly,  a  jaundiced  tint  appeared  upon  the  face, 
and  very  shortly  the  whole  skin  was  colored  bright  yellow ; 
there  was  intense  mental  apathy ;  the  urine  was  loaded  with 
bile-pigment,  and  the  f^ces  clay-colored.  This  state  of  things 
lasted  only  about  a  week,  and  then  very  rapidly  disappeared ; 
but  as  the  jaundice  subsided  there  was  a  partial  recurrence  of 
the  neuralgic  pains,  which,  for  a  day  or  two,  were  as  severe  as 
they  had  ever  been.  The  other  four  cases  of  hepatalgia  which 
I  have  seen,  including  that  of  the  man  above  mentioned,  have 


ON  NEURALGIA,  57 

all  been  in  persons  in  advanced  life ;  but,  except  the  latter, 
neither  of  them  displayed  any  symptoms  of  disordered  biliary 
secretion;  and  the  diagnosis  (as  to  situation,  for  the  character 
of  the  attacks  was  manifestly  neuralgic)  rested  mainly  on  the 
fact  that  the  pain  radiated  to  the  shoulder. 

There  reimains  to  be  noticed  one  clinical  feature  of  the  dis- 
ease, which,  I  believe,  is  characteristic;  namely,  the  peculiar 
mental  depression  which  attended  all  the  cases  I  have  seen, 
but  Vv'^as  most  marked  in  the  tv/o  in  which  jaundice  occurred. 
In  the  girl  above  referred  to,  the  apathy,  during  tlie  period 
when  there  was  jaundice  but  no  pain,  was  even  alarming;  it 
reminded  one  of  the  mental  state  in  commencing  catalepsy ; 
during  the  painful  stages  it  was  more  like  the  gloom  of  suicidal 
melancholia.  Of  course,  the  acute  mental  anxiety  which  this 
patient  had  suffered  would  account  for  a  good  deal  of  this;  but 
the  symptom  was  as  distinct,  though  less  severe,  in  the  case  of 
an  elderly  lady,  whom  I  have  attended  on  another  occasion 
for  migraine ;  here  there  was  no  recognizable  source  of  anxiety ; 
and,  on  the  other  hand,  there  was  no  I'eason  to  suspect  the  re- 
tention of  bile-elements  in  the  blood.  It  seems,  therefore,  as 
if  an  essentially  depressing  influence  on  the  mind  v/as  excited 
by  hepatic  neuralgia;  or  else,  that  emotional  causes  are  the 
chief  source  of  the  malady. 

Neuralgia  of  the  Heart. — If  there  be  any  hesitation  in  treat- 
ing this  disease  as  exactly  conterminous  with  angina  pectoris, 
it  can,  I  think,  be  only  reasonably  justified  on  two  grounds: 
In  the  first  place,  it  may  be  urged  that  acute  pain  of  the  neu- 
ralgic type  is  not  always  present  in  angina  pectoris;  and, 
secondly,  it  may  be  urged  that  many  cases  of  painful  neurosis 
of  the  heart  have  been  observed,  in  which  the  recurrence  of 
pain  with  some  amount  of  cardiac  embarrassment  has  gone  on 
for  years,  whereas  the  popular  conception  of  true  angina  al- 
most necessarily  involves  rapid  fatality. 

There  is  doubtless  some  force  in  these  objections,  especially 
in  the  second,  for  it  does  seem  rather  inconvenient  to  call  by 
the  same  name  so  deadly  a  disorder  as  the  worst  form  of  an- 
gina, and  so  comparatively  harmless  a  malady  as  some  of  those 
instances  of  chronic  tendency  to  spasmodic  pain  of  the  heart 
which  are  not  very  uncommon,  and  in  which  the  patient  sur- 
vives, perhaps,  to  an  old  age.  Yet,  after  all,  there  is  the 
greatest  ditliculty  in  drawing  any  rational  line  of  distinction ; 
for  the  basis  of  the  affection  seems  the  same  in  every  case, 
whether  i^ani  or  spasm  be  the  predominant  feature,  and 
whether  the  course  of  the  disease  be  long  or  short.  All  that 
appears  to  be  necessary  for  its  production  is  a  certain  origi- 
nally neurotic  temperament  (with  possibly  some  congenital 
weakness  or  some  post-natal  disease  of  that  part  of  the  spinal- 
cord  centres  which  Von  Bezold  has  described  as  furnishing 
three-fourths   of  the  propulsive  jjower  of  the  heart)  and  the 


58  .  ON  NEURALGIA. 

presence  of  almost  any  kind  of  difficulty  or  embarrassment  of 
the  action  of  the  heart.  The  most  common  source  of  this  em- 
barrassment is  perhaps  failure  of  nutrition  in  the  muscular 
walls  of  the  heart,  from  disease  of  the  coronary  arteries.  In- 
deed, it  is  not  known  that  any  organic  change  of  the  heart  or 
great  vessels,  even  of  the  slightest  kind,  is  necessary  to  the 
production  of  angina ;  on  the  contrary,  there  is  every  reason  to 
think  that  mere  fatigue  and  depression  may  briug  on  the  at- 
tacks in  persons  of  a  strongly  nervous  temperament.  For  my 
own  pai't,  I  am  inclined  to  believe,  however  that  there  really 
always  is  disease  somewhere  in  the  cardiac  centre  of  the  spinal 
cord,  though  that  disease  may  consist  in  no  more  than  a  dis- 
position to  minute  interstitial  atroi^hy.  But  we  shall  say  more 
about  this  presentlj^. 

It  is  at  any  rate  certain  that  cardiac  neuralgia  is  always  a 
most  grave  complaint,  from  the  almost  total  uncertainty 
whether  succeeding  attacks  will  not  involve  a  fatal  amount  of 
spasm.  As  for  the  expression  anguia  pectoris,  it  is  just  one  of 
those  mischievous  terms  which,  arising  out  of  the  mystified 
ignorance  in  which  the  elder  jjhysicians  found  themselves  as 
to  the  pathology  of  internal  diseases,  have  since  been  attached 
in  turn  to  various  definite  organic  changes,  with  none  of  which 
they  had  any  essential  connection ;  and  it  is  therefore  much 'to 
be  wished  that  it  could  be  altogether  done  away  with.  At  the 
same  time,  there  is  so  much  that  is  peculiar  in  the  case  of 
cardiac  neuralgia,  owing  to  the  importance  of  the  organ  af- 
fected, that  it  will  be  necessarj^  here  to  treat  not  merely  its 
symptoms,  but  also  its  diagnosis,  prognosis,  etiology,  patho- 
log}',  and  treatment,  in  a  separate  and  continuous  manner. 

Clinical  History  and  Symptoms. — Cardiac  neuralgia 
usually  shows  itself  for  the  first  time  with  considerable  abrupt- 
ness. The  patient  may  or  may  not  have  been  consciously  ill  be- 
fore the  actual  seizure,  but  it  rarely  happens,  even  when  the 
heart  has  notoriously  been  the  subject  of  some  organic  disease, 
that  there  has  been  any  thmg  to  lead  hun  to  expect  the  kmd  of 
attack  from  which  he  now  suffers.  In  the  midst  of  some  little 
unusual  effort,  or  even  without  this  kind  of  provocation,  sud- 
denly the  patient  is  attacked  with  severe  pain,  usually  at  the 
lower  part  of  the  sternum ;  this  pain  darts  through  to  the  back 
and  left  shoulder,  and  nearly  always  runs  down  the  left  arm. 
Sometimes,  uideed,  it  is  felt  acutely  over  a  large  area  of  the 
chest,  and  runs  down  both  arms ;  this  is  the  case  in  a  patient 
now  under  my  care,  in  whom  the  affection  is  more  obviously 
a  neurosis,  and  less  attended  with  coarse  organic  changes,  than 
is  usually  the  case.  Along  with  the  pain,  whicli  is  always  very 
distressing,  but  varies  greatly  in  severity  in  different  cases, 
there  is  a  Variable  amount  of  another  sensation  which  can  be 
compared  to  nothing  but  cramp,  or  rather  compression;  the 
patient  usually  describes  it  as  feeling  as  if  some  one  were  grasp- 


ON  NEURALGIA.  59 

ing  the  heart  in  his  hands,  and,  when  this  sensation  is  at  all 
prominent,  the  idea  of  iuipending-  death  is  most  strongly  im- 
pressed on  the  suii'erer's  mmd.  His  outward  appearance  seems 
to  confirm  the  idea.  In  cases  where  the  sense  of  compression 
is  great,  the  face  is  of  an  ashen  gray;  the  lips  white,  with  a 
faint  livid  tinge;  tlie  pulse  small,  feeble,  and  unrhythmical,  or 
imperceptible,  at  the  wrjst ;  cold  perspiration  breaks  out  upon 
the  face ;  in  shoi't,  all  the  signs  of  approaching  dissolution  are 
present.  In  cases  where  tiie  suffering  is  chiefly  or  entirely 
confined  to  severe  pain,  of  a  darting  or  burning  character, 
the  state  of  the  circulation  is  often  different.  The  heart  bounds 
against  the  ribs,  in  rapid  and  painful  palpitation,  the  face  is 
flushed  deep  crimson,  the  pulse  at  the  wrist  is  large,  bounding, 
but  very  compressible ;  in  fact,  the  outward  appearance  of  the 
patient  is  so  different  from  that  of  one  who  suffers  from  the 
more  depressing  kind  of  angina,  that  it  is  difficult  to  consider 
the  two  affections  as  essentially  siixiilar.  But  there  can  be  no 
question,  if  we  carefully  examine  the  matter,  that  they  are 
mere  varieties  of  the  same  disorder,  especially  as  they  both  may 
successively  occur  in  the  same  person. 

The  course  of  cardiac  neuralgia  varies  extremely.  Supposing 
the  malady  to  be  jDurely  neurotic,  and  not  complicated  with 
organic  disease,  which  forms  a  constant  source  of  cardiac  em- 
barrassment, then  the  patient  may  only  experience  one  or  two 
attacks,  under  some  special  circumstances  of  exhaustion,  which 
may  never  recur;  or,  on  the  other  hand,  he  may  develop  a 
strong  tendency  to  cardiac  neuralgia  which  may  beset  him  dur- 
ing almost  any  number  of  j^ears.  In  the  latter  case,  it  is  an 
even  chance  whether  the  patient  will  at  last  sink  from  the  an- 
ginal affection ;  for,  even  supposing  him  to  escape  any  fatal  in- 
tercurrent disease  of  an  independent  nature,  the  fatal  event 
may  be  at  last  produced  by  cerebral  softening,  or  by  apoplexy, 
or  other  central  nervous  disease.  In  fact,  the  frequency  with 
which  the  latter  kind  of  termination  occurs  is  very  significant 
of  the  essential  nature  of  the  disease. 

The  manner  in  which  cardiac  neuralgia  commences  varies 
very  greatly.  In  the  celebrated  case  of  Dr.  Ai'nold,  the  first 
attack  did  not  occur  till  he  was  forty-seven  years  of  tige ;  it  at 
once  assumed  full  intensity,  and  proved  fatal  in  two  hours  and 
a  half.  There  is  also  reason  to  believe  that  Dr.  Arnold's  father 
died  in  a  first  attack  of  angina.  I  have  myself  known  a  fii'st 
attack  prove  fatal  in  the  course  of  an  hour ;  there  was  very 
considerable  ossification  of  the  coronary  arteries  and  fatty  de- 
generation of  the  heart-walls.  Again,  there  are  many  cases 
which  commence  gradually,  and  with  great  mildness,  and  with 
little  appearance  of  danger  to  life  in  the  first  attacks ;  but  the 
subsequent  attacks  are  progressively  more  severe  and  dange- 
rous up  to  a  fatal  result,  after  weeks,  months,  or  years.  On 
the  other  hand,  I  have  known  three  instances  in  which  the 


60  .  ON  NEURALGIA. 

first  attacks  of  spasmodic  lieart-paiii  very  nearly  proved  fatal, 
but  the  subseqweiit  fits  were  milder  (in  one  there  was  no  second 
attack) :  all  those  patients  are  living,  six,  eight,  and  three 
years  respectively,  after  their  first  attacks. 

It  can  hardly  be  doubted  that  neuralgic  spasm  is  the  true 
cause  of  sudden  death  in  some  cases  of  stenosis  of  the  aortic 
orifice,  which,  but  for  some  accidental  circumstances,  would 
not  have  died  suddenly  at  all,  but  would  have  gone  through  a 
long  and  gradual  course  of  deterioration.  I  j)articularly  re- 
member an  instance  in  which  extreme  and  calcareous  constric- 
tion of  the  aortic  orifice,  in  a  boy  not  yet  come  to  ]3uberty,  was 
entirely  unsuspected,  until  one  day,  in  running  fast,  he 
screamed  out  and  fell  down,  and  v/as  almost  instantaneously 
dead.  I  remember  another  case  very  similar,  in  which  extreme 
mitral  constriction  produced  almost  as  sudden  death,  appa,- 
rently  from  painful  spasm,  under  the  same  kind  of  exertion. 
On  the  other  hand,  sudden  death,  when  x>roduced  by  the  form 
of  heart-disease  which  (as  Dr.  Walshe  points  out)  is  most 
likely  to  cause  such  a  catastrophe,  viz. ,  aortic  regurgitation 
pure,  witliout  hypertrophy,  does  not  seem  to  be  due  to  painful 
spasm,  but  to  simple  and  complete  failure  of  the  muscular 
power,  and  is  perhaps  partly  of  the  nature  of  paralysis  from  a 
syncopal  condition  of  the  brain,  the  imhypertrophied  heart 
having  become  for  the  moment  unable  to  supply  blood  enough 
to  the  brain  to  carry  en  nervous  function  at  all. 

A  good  instance  of  the  form  which  angma  takes,  when  the 
element  of  organic  cardiac  change  is  well  pronounced,  was 
afforded  by  the  case  of  a  young  gentleman  recently  under  my 
care.  He  was  twenty -one  years  of  age,  and  from  early  boy- 
hood had  been  accustomed  to  a  great  deal  of  muscular  exercise ; 
in  fact,  it  is  probable  that  he  had  undermmed  his  health  by  the 
frequent  and  extraordinarily  long  walks  which  he  took,  for 
his  frame  was  particularly  small  and  slight,  and  the  muscles 
small  and  soft.  He  came  of  a  family  in  whom  the  tendency  to 
neurotic  disorders  is  obviously  very  strong ;  both  his  father 
and  his  brother  are  subject  to  bad  attacks  of  migraine,  and  he 
had  himself  repeatedly  suffered  from  the  same  thiug.  The 
family  disposition,  altogether,  is  highlj^  nervous  and  excitable. 
The  remarkable  circumstance  in  this  young  gentleman's  case 
is,  that  although  he  had  taken  for  years  an  extraordinary 
amount  of  pedestrian  exercise  (including  mountain-climbing), 
and  latterly  had  exchanged  this  for  the  even  more  trying  exer- 
tion of  rowing,  he  had  never  suffered  from  any  noticeable 
symptom  of  cardiac  distress  up  to  the  very  day  of  his  anginal 
attack.  For  some  months,  however,  he  had  been  growing 
thin  and  pale,  and  I  had  given  him  certain  cautions,  and  had 
made  him  take  cod-liver  oil  and  steel,  as  I  entertained  some 
fears  of  his  becoming  phthisical.  On  the  day  of  the  attack 
there  was  nothing  particular  in  his  appearance,  but  he  com- 


ON  NEURALGIA.  61 

plained  of  a  slig-ht  cold,  and  had  no  appetite  for  his  six  o'clock 
dinner.  He  retired  to  rest  at  eleven  o'clock,  having  taken  a 
small  dose  of  laudanum  and  chloric  ether  for  his  cold.  In  less 
than  half  an  hour  he  awoke  out  of  his  sleep  in  fearful  agony ; 
so  severe  and  prostrating  was  the  anginoid  pain  that  he  had 
the  greatest  difficulty  in  crawling  out  of  bed  to  unlock  his  door. 
I  found  him  bathed  in  cold  sweat,  pale  as  a  sheet,  and  with 
livid  lips.  He  groaned  with  pain,  which  he  described  as 
"  cutting  him  across  "  from  the  sternal  notch  to  the  nipple,  and 
going  down  the  left  arm ;  and  there  was  so  marked  a  catching 
of  the  breath  as  to  make  it  almost  certain  that  there  was 
diaphragmatic  spasm ;  in  fact,  it  was  this  which  alarmed  him, 
and  made  him  say  that  he  was  certainly  dying.  The  heart, 
however,  appeared  to  be  j^ushed  up  somewhat,  and  it  v/as 
thought  that  this  might  be  partly  due  to  stomacliic  distention, 
but  a  mustard  emetic  produced  little  effect.  The* heart-sounds 
were  so  weak  that  the  presence  or  absence  of  bruit  could  not  be 
safely  predicated;  meantime,  the  pulsations  intermitted  in  a 
most  alarming  manner.  Large  doses  of  brandy  and  sulphuric 
ether  at  length  (after  several  relapses)  seemed  to  subdue  the 
pain  and  spasm,  and  in  an  hour  and  a  half  from  the  com- 
mencement of  the  attack  the  patient,  though  utterly  worn  out, 
sank  into  a  tolerably  quiet  sleep.  The  spasms  did  not  recur, 
but  for  the  next  three  or  four  days  he  was  in  a  state  of  great 
exhaustion.  When  his  tranquillity  of  mind  had  been  somewhat 
restored,  a  careful  physical  examination  was  made,  and  it  was 
discovered  that  there  was  a  moderately  loud  and  somewhat 
thrilling  systolic  bruit  at  the  site  of  the  aortic  valves,  and  ex- 
tending some  distance  into  the  vessels.  The  pulsfe  still  re- 
mained strikingly  intermittent,  and,  though  of  fair  volume, 
was  very  compressible.  Percussion  indicated  considerable  en- 
largement of  the  heart,  and  the  j)hysical  signs  pointed,  on  the 
whole,  to  dilatation  without  hypertrophy.  Some  doubtful 
signs  of  consolidation  were  observed  at  both  apices  of  the  lungs. 
It  is  remarkable  that,  notwithstanding  the  serious  degree  of 
cardiac  mischief  indicated  by  the  above  signs,  the  patient,  a 
very  few  days  later,  took  a  walk  of  some  ten  miles,  and, 
though  much  exhausted,  suffered  no  recurrence  of  his  formid- 
able spasmodic  symptoms  in  consequence  of  this  imprudence. 
He  v/as  sent  to  the  mild  climate  of  Mentone,  and  subsequently 
to  Nice;  the  angina  never  recurred,  but  the  patient  remained 
weak,  and  liable  to  more  or  less  dyspnoea  for  fifteen  or  sixteen 
months;  now  he  lives  an  ordinary  life,  doing  his  duty  as  a 
Swiss  citizen  and  officer.  The  cure  of  some  hemorrhoids, 
about  twelve  months  after  the  anginal  attack,  seemed  greatly 
to  benefit  him.  What  the  future  of  this  case  may  be  it  is 
impossible  to  say,  but  of  course  there  is  no  security  against 
the  angina  recurring  on  extraordinary  excitement  or  over- 
exertion. 


62  .ON  NEURALGIA. 

Of  the  purely  neurotic  variety  of  angina  it  is  impossible  to 
determine  the  frequency  ;  but  it  seems  certain  that  the  affec- 
tion is  common,  and  I  sus^^ect  that  it  occure  more  often  than  is 
supposed,  as  a  sequel  to  asthma.  The  probable  relation- 
ship between  the  two  affections  was  long  ago  indicated  by 
Kneeland."^  I  have  certamly  seen  several  cases  of  asthma  in 
which  spasmodic  pain  of  the  heart  has  occurred  on  various  oc- 
casions after  or  during  a  very  severe  asthmatic  paroxysm. 
One  case  was  that  of  a  gentleman,  of  a  highly  delicate  and 
neurotic  temperament,  who  had  suffered  for  fifteen  or  sixteen 
years  from  well-marked  spasmodic  astlima:  this  case  is  re- 
markable as  an  illustration  of  several  points  which  will  be 
dwelt  upon  in  other  x^ai^ts  of  this  volume.  For  some  time  be- 
fore the  outbreak  of  cardiac  neuralgia,  he  had  sufPered  repeat- 
edly from  severe  facial  neuralgia,  and  these  attacks  on  more 
than  one  occasion  culminated  in  facial  erysipelas,  or  what  was 
entirely  indistinguishable  from  that  affection.  He  then  began 
to  suffer  from  cardiac  i^ain  and  spasm  after  his  asthmatic  par- 
oxysms, and  these  new  symptoms  sjDeedily  assumed  the  form  of 
a  very  severe  intermittent  angina :  in  several  of  the  attacks  he 
appeared  about  to  die.  The  i3ain  in  these  attacks  is  very  severe ; 
it  occux^ies  a  lai'ge  area  in  the  centre  of  the  chest,  and  runs 
down  both  arms;  and,  v.'hat  is  strange,  the  arms  become  re- 
markably swollen  and  hot  after  an  unusually  long  bout  of 
pam,  I  presume  from  vaso-motor  paralysis.  At  present  (nearly 
five  years  from  the  commencement  of  the  cardiac  neuralgia) 
the  cardiac  attacks,  though  of  frequent  occurrence,  are  decid- 
edly more  tolerable  than  they  were  at  first,  and  the  sense  of 
squeezing  or  pressure,  though  never  quite  absent,  does  not 
amomit  to  the  dreadful  sort  of  feeling  which  used  to  convince 
the  patient  that  he  was  at  the  point  of  death.  In  this  case,  the 
heart  has  been  repeatedly  explored  without  anj  j)Ositive  result, 
and  the  pulse  has  been  frequently  tested  by  the  sphygmogTaph. 
The  latter  instrument  is  the  only  mode  of  examining  by  which 
I  have  been  able  to  elicit  even  suspicious  evidence  that  there  is 
any  organic  change  of  the  heart ;  by  means  of  it  I  have  lately 
obtained  some  grounds  for  suspecting  that  there  is  slight  dila- 
tation of  the  heart,  but  it  is  uncertain  whether  anythuag  of  the 
kind  existed  at  the  commencement  of  the  anginal  syraptoms. 
In  this  case  I  am  inclined,  on  the  whole,  to  doubt  whether  the 
angina  will  ever  prove  fatal,  unless  the  bronchitis,  with  which 
the  patient's  asthma  has  for  some  time  past  been  liable  to  be 
complicated,  should  occur  in  a  severe  form ;  ni  that  case  it  is 
likely  that  the  additional  embarrassment  of  the  heart  s  action 
may  bring  on  fatal  spasms. 

One  of  the  best  examples  I  ever  saw  of  cardiac  neuralgia 
(ultimately  proving  fatal)  was  one  of  which  the  origin  was  en- 

*Amer.  Jour.  Med.  Science,  Jan.  1850. 


ON  NEURALGIA.  63 

tirely  nervous.  It  occurred  in  a  gontleman  in  the  prime  of 
life,  and  naturally  of  a  powerful  physique,  whose  very  active 
and  capacious  mind  had  been  greatly  overwrought.  The 
whole  weight  of  responsibility  for  an  undertaking  of  national 
importance,  and  which  involved  great  difficulties  and  much 
anxiety,  for  a  long  time  rested  on  his  shoulders.  Under  these 
influences  he  broke  down,  and  never  effectually  recovered  him- 
self.  At  first,  the  symptoms  were  those  of  mere  ordinary  ner- 
vous exhaustion,  but  after  a  time  he  became  subject  to  fre- 
quently recurring  attacks  of  agonizing  spasmodic  heart-pain, 
with  a  sense  of  impending  dissolution;  from  these  he  was  in- 
variably relieved  by  the  inhalation  of  a  small  amount  of  chlor- 
oform. Not  the  slightest  organic  heart  mischief  could  be  de- 
tected, either  during  life  or  after  death. 

Pathology. — Angina  stands  in  so  peculiar  a  position  that  I 
deem  it  w^ell  to  discuss  it  as  a  whole,  and  not  merely  its  clinical 
history,  in  this  place.  As  I  have  already  said,  there  is  notliing 
in  the  njorbid  appearances  found  after  death  which  is  charac- 
teristic of  fatal  angina,  and  in  the  milder  kinds  of  cardiac  neu- 
ralgia we  are  driven  back  upon  the  general  probabilities 
which  we  deal  with  in  reasoning  as  to  the  origin  of  neuralgias 
in  general.  As  to  morbid  changes,  it  is  impossible  to  say  any 
thijig  more  exhaustive  of  the  facts  known  than  the  following 
words  of  Dr.  Walshe  :'*  "First,  there  are  few,  if  any,  struc- 
tural diseases  either  of  the  heart,  its  orifices,  and  its  nutrient 
arteries,  or  of  the  aorta,  found  recorded  in  the  narratives  of  the 
post-mortem  examination  of  different  victims  of  angina  pecto- 
ris. Secondly,  there  is  no  conceivable  disease  of  these  struct- 
ures and  parts  which  has  not  in  various  individuals  reached  the 
highest  point  of  development,  without  anginal  paroxysms,  even 
of  a  slight  kind,  having  occurred  during  life ;  to  this  proposi- 
tion extensive  calcification  of  the  coronary  arteries  perhaps  fur- 
nislies  a  solitary  exception.  Thirdly,  the  organic  changes  most 
frequently  met  with  have  been  fatty  atrophy  and  flabljy  dilata- 
tion of  the  heart ;  obstructive  disease  of  the  coronary  arteries 
by  atheroma  and  calcification  of  the  orifice  and  arch  of  the 
aorta.  Fourthly,  the  rarest  have  been  hypertrophy  and 
hypertrophy  with  dilatation.  In  truth,  it  may  be  doubted 
whether  these  conditions  in  their  genuine  form,  v/ithout  any 
combination  of  fatty  atrophy,  have  ever  been  the  sole  morbid 
states  present."  From  all  this  Dr.  Walshe  concludes  that 
the  fundamental  mischief  of  angina  is  neurotic;  and, 
while  he  believes  that  some  textural  change  in  the  heart 
is  necessary  as  an  irritant  to  generate  this  neurotic  suscepti- 
bility to  dynamic  disturbance  from  slight  causes,  he  recog- 
nizes only  one  common  quality  in  these  various  cardiac 
lesions,  viz.,   that  they  indicate  mal-nutrition  and  weakened 

*  "Diseases  of  the  Heart  and  Great  Vessels."    Third  edition,  1862, 


64  .    ON  NEURALGIA. 

power.  Dr.  Walshe  does  not  appear  to  believe  the  neurotic 
disturbance  can  arise  without  the  kind  of  irritation  wliich 
is  kept  up  by  such  cardiac  changes.  In  spite,  lio\yever  of 
the  great  authority  of  this  author,  it  certainly  seems  very 
probable  that  organic  cardiac  change  is  by  no  means  necessary 
to  the  occurrence  of  angina,  and  this  for  two  reasons :  In  tlie 
first  place,  though  full  reliance  may  be  placed  on  the  details  of 
the  post-mortem  examinations  made  by  Dr.  Walshe  himsslf, 
they  are  very  few  (twelve  or  fourteen)  in  number ;  and  other 
observers  who  have  recorded  cases  are  as  httle  trustworthy, 
considering  their  evident  tendency  to  find  some  disease  where 
none  exists,  as  the  older  narratives  which  Dr.  Walshe  natu- 
rally distrusts  were  unreliable  when  they  declared  that  no 
morbid  change  was  present.  And,  secondly,  his  view  halxlly 
takes  it  into  account  that  there  are  still  two  other  alternatives, 
even  supposing  that  one  or  other  of  the  a,bove  changes  is  ad  ways 
present :  (a)  it  is  possible  that  the  neurotic  disturbance  and  the 
cardiac  lesions  might  both  be  the  result  of  a  common  cause ;  and 
(6)  it  is  even  possible  that  the  altei'ations  of  tissue  in  the  heart 
and  vessels  are  due  to  a  morbid  influence  proceeding  from  a 
diseased  nervous  centre,  either  spinal  or  sympathetic. 

As  for  the  state  of  the  muscular  fibre  Avhich  immediately 
causes  death,  Dr.  Walshe  is  of  opinion  that  it  is  paralytic  rather 
than  spasmodic ;  and  he  urges  in  favor  of  this  view  the  fact 
that  in  his  large  experience  he  has  never  known  the  pulse  to 
intermit  during  the  attack — it  was  always  regular,  however 
feeble.  In  this  respect  he  is  in  op]30sition  to  some  distinguished 
authors,  however,  and,  as  he  allows  that  he  has  not  seen  origi- 
nal attacks  in  their  height,  but  only  when  they  were  subsiding, 
it  would  be  possible  that  the  spasm  stage  had  subsided.  How- 
ever Dr.  Walshe  admits  that  there  may  be  exceptional  cases  in 
which  spasm,  or  cramp  (i.  e.,  spasm  with  rupture  or  dislocation 
of  fibre),  really  occurs,  and  suggests  that  this  is  very  probalile 
in  the  rare  cases  where  death  is  attended  by  general  tetanic 
spasm  of  the  muscles.  As  far  as  my  own  opinion  is  worth  any- 
thing, I  could  insist  that  at  least  Dr.  Walshe  must  be  right 
as  against  Dr.  Latham  and  Dr.  Inman,  in  affirming  that 
cardiac  cramp,  if  it  occu.rs,  is  the  consequence  and  not  the 
cause  of  the  neuralgic  pain. 

Causes. — In  some  respects  it  is  impossible  to  deal  with  the 
etiology  of  angina  apart  from  the  pathology,  just  as  we  re- 
marked with  regard  to  neuralgias  in  general.  But  there  are 
certain  special  features  in  the  causation  of  angina  pectoris 
which  require  separate  notice,  just  as  there  are  special  features 
in  its  pathology. 

Of  predisposing  causes,  the  majority  are  the  same  as  those  of 
which  we  have  spoken  in  our  general  remai-ks  on  the  etiology 
of  neuralgia.  A  family  history  of  a  tendency  to  the  gi'aver 
neuroses  is  I  believe  universal,  and,  indeed,  direct  i}iheritance 


ON  NEURALGIA.  65 

of  angina  from  father  to  son,  as  in  Arnold's  case,  has  happened 
in  many  recorded  instances.  A  very  remarkable  fact  is  the 
time  of  life  at  which  the  disease  originally  appears:  Walshe 
says  it  is  rare  before  the  age  of  hity,  but  excessively  rare  before 
forty.  This  is  very  interesting,  as  placing  angina  in  the  same 
category  with  the  severe  and  intractable  forms  of  facial  and 
other  neuralgias  which  are  so  highly  characteristic  of  the 
period  of  bodily  degeneration.  One  may  even  gather  a  sus- 
picion, though  it  goes  but  a  short  way  toward  proof,  that  the 
essence  of  angina  is  an  atrophy  either  of  the  cardiac  plexus  or 
of  the  nucleus  of  the  vagus,  or  of  that  part  of  the  spinal  cord, 
already  mentioned,  which  seems  to  be  the  centre  of  the  major 
part  of  the  propulsive  force  of  the  heart. 

On  the  other  hand,  there  is  a  fact,  even  more  remarkable 
than  the  influence  of  age,  which  tells  somewhat  in  a  contrary 
direction.  There  is  a  naost  extraordinary  preponderance  of 
males  among  the  victims  of  angina.  Sir  John  Forbes  found 
eighty  males  among  eighty-eight  patients  suffering  from  this 
disease.  On  the  first  blush  it  would  seem  natural,  indeed 
almost  necessary,  to  explain  this  by  supposing  that,  as  men 
take  a  much  larger  amount  of  strong  physical  exercise  than 
women,  they  will  furnish  a  much  larger  proportion  of  subjects 
in  whom  an  ill-nourished  heart  will  break  down  under  its 
work  and  be  seized  either  with  paralysis  or  cramp  (for  the  two 
states  are,  after  all,  not  opposed  to  each  other,  but  only  vaiy- 
ing  shades  of  debility.)  Upon  this  theory  one  would  have  to 
believe  that  the  origin  of  angina  was  far  more  peripheral  than 
central,  if  we  are  to  siippose  that  spasm  is  the  ordinary  condi- 
tion of  the  heart  daring  the  anginal  paroxysm.  But  we  do 
not  know  that  this  is  the  case ;  indeed,  there  are  many  argu- 
ments against  it ;  and  at  any  rate  we  must  suppose  that  in  a 
considerable  number  of  cases  the  muscular  state  is  one  of  re- 
laxation from  want  of  power.  And  certainly  it  is  infinitely 
more  probable  that  paralysis  or  s]3asm  of  a  muscular  viscus 
should  occur  as  a  reflex  consequence  of  neuralgia  occurring  in 
a  nerve  whose  central  nucleus  was  closely  connected  with  the 
motor  centre  of  the  organ,  than  that  mere  paralysis  of  the  vis- 
cus should  convey  a  reflex  impression  to  sensitive  nerves  which 
should  express  itself  in  the  form  of  acute  pain.  It  must  be 
confessed  that  the  matter  hangs  in  doubt;  but  the  evidence  is, 
on  the  whole,  very  strong  for  the  belief  that  central  nervous 
mischief  is  the  most  important  element  in  angina. 

Another  very  important  class  of  predisposing  causes  of 
angina  is  the  mental  emotions.  It  is  notorious  that  the  disease 
is  one  not  common  in  humble  life ;  it  chiefly  assails  the  more 
cultivated  class,  and  especially  men  who  are  much  engaged  in 
affairs  in  which  great  mental  anxiety  or  emotion  is  mingled 
with  severe  toil  of  intellect.  Thus  the  professional  class  has 
always  shown  a  sad  predominence  in  tendency  to  this  disease ; 
5 


66  .      ON  NEURALGIA. 

a  large  nmnber  of  the  victims  have  been  found  among  over- 
worked clergymen,  lawyei'S,  doctors,  engineers,  etc.  The 
various  forms  of  heart-lesion  which  have  been  ah'eadj^  men- 
tioned must  doubtless  be  considered  highly  predisposing,  when 
there  is  ah'eady  a  neurotic  susceptibility,  more  especially  those 
which,  like  fatty  degeneration  of  the  muscular  structure, 
greatly  enfeeble  the  heart's  action.  I  do  not  believe  that  these 
diseases  will  cause  angina  in  a  person  who  is  free  from  the 
peculiar  nervous  susceptibility. 

The  immediately  exciting  causes  are  very  various.  The 
most  common  of  "all  is  doubtless  some  exertion  of  body,  or  dis- 
tress of  mind,  which  at  once  agitates  and  embarrasses  the 
heart's  action;  and,  where  the  tendency  to  cardiac  neuralgia 
has  once  declared  itself  by  an  actual  attack,  very  slight  ex- 
cesses of  this  kind  will  usually  suffice  to  re-excite  the  paroxysm. 
Sexual  excitement  is  particularly  provocative  of  the  attacks,  in 
the  predisposed.  But  much  slighter  causes  suffice,  in  those 
cases  \yhere  the  mitability  of  the  cardiac  nerves  has  become 
very  intense :  thus  a  mere  puff  of  cold  air  upon  the  face,  and 
other  similar  slight  peripheral  impressions,  by  actmg  m  a  reflex 
manner,  have  frequently  produced  the  paroxysm.  I  have  seen 
an  extremely  severe  angmal  attack  brought  on  by  the  slight 
shock  of  the  sudden  slamming  of  a  door.  And  it  would  even 
appear  that  some  peripheral  excitements  of  a  powerful  kind 
may  operate  with  such  force  as  to  generate  angina  in  persons 
who  are  merely  m  weak  health,  but  who  cannot  be  supposed  to 
be  specially  predisposed  to  angina ;  it  is  in  this  waj^,  I  presume, 
that  we  must  explam  the  extraordinary  occurrence,  reported 
"by  Guelineau,*  of  an  epidemic  outbreak  of  angina,  in  which 
numbers  of  men,  belonging  to  a  ship's  crew,  were  simul- 
taneously affected.  The  men  had  been  badly  fed,  and  their 
quartei*s  were  very  unhealthy ;  but  the  powerful  exciting  cause 
seemed  to  be  the  rapid  change  from  a  very  hot  to  a  very  cold 
climate.  Not  only  were  there  many  'cases  of  severe  angina, 
but  other  forms  of  neuralgia,  and  severe  colics,  were  observed 
in  others  of  the  crew.  Among  the  sources  of  periphei'al  irri- 
tation which  ought  to  be  particularly  considered,  in  rela.tion  to 
angina,  are  the  diseases  and  injuries  which  produce  powerful 
irritation  of  the  branches  of  the  trigemmus.  Lederer's  cases  f 
of  violent  vomiting  and  cardiac  pain,  from  the  operation  of 
pivoting  teeth,  and  Eemak's  instances  I  of  violent  palpitation 
and  cardiac  distress,  produced  by  disease  of  the  last  molar 
tooth,  seem  to  show  that,  both  through  the  vagus  and  the  sym 

^Gnz.  des  Bop.,  114,  117,  120.     1862. 

f  Ww7i  Med.  Presse,  xxiv.,  1866  ;  Syd.  Soc.  Yearbook,  1865-66, 
p.  120. 

t  Berlin  Klin.  "Wocli.,  1865  ;  Syd.  Soc.  Yearbook,  1865-66,  p. 
120. 


ON  NEURALGIA.  67 

pathetic,  the  most  powerful  reflex  action  may  be  proclucecl  in 
the  heart  and  stomach  by  irritation  of  the  fiftli  cranial. 

Another  occasional  excitant  of  angina  is  an  interesting  link 
in  the  chaui  of  proof  that  angina  is  au  fond  a  neuralgia, 
namely,  the  malarial  poison,  which  has  in  a  good  many  well- 
observed  cases  distinctly  induced  the  disease.*  Finally,  the 
occasional  influence  of  excessive  tobacco-smoking  in  pro- 
ducing anginal  attacks,  in  persons  not  affected  with  any  dis- 
coverable organic  heart-disease,  affords  the  strongest  corro- 
borative evidence  of  the  essentially  neurotic  character  of  angina 
pectoris.  M.  Beauf  has  recorded  many  serious,  and  some 
fatal,  cases  from  this  cause.  Probably  in  both  the  malarial 
cases  and  those  induced  by  tobacco-poisoning  the  special 
neurotic  tendency  existed  already. 

Diagnosis. — The  diagnosis  of  angina  pectoris,  in  those  severe 
forms  with  which  the  popular  idea  of  the  disease  is  chiefly  con- 
nected, can  hardly  be  a  matter  of  much  difficulty.  When  we 
see  an  elderly  man  lying  in  a  state  of  deathly  collapse,  which 
has  suddenly  come  on,  with  cold  sweats  and  nearly  extinguished 
pulse,  gasping  for  breath,  and  complaining  of  intolerable  pahi 
in  the  chest  and  arm,  and  a  sense  of  oppression  more  dreadful, 
even,  than  the  pain,  we  can  hardly  doubt  that  the  case  is  an- 
gina in  its  worst  form.  On  the  other  hand,  when  a  j^oung  x^er- 
son,  especially  a  young  female,  complains  even  of  very  severe 
pain  in  the  cardiac  region,  together  witii  breatiilessness,  es- 
pecially if  the  heart  be  palpitating  and  the  face  flushed,  the 
diagnosis,  though  not  immediately  certain,  already  very 
strongly  indicates  the  probability  that  the  case  is  not  one  of 
primary  cardiac  neuralgia  at  all.  These  are  extreme  instances, 
however.  In  more  doubtful  cases,  the  following  are  the  prin- 
cipal materials  for  decision : 

Affirmative  Signs.  Negative  Signs. 

1.  Age  over  forty.  1.  Age  under  forty. 

2.  Male  sex.  2 .     Female  sex. 

3.  Nervous  temperament  (per-    3.  Temperment  either  not  ner- 

sonal     and  family)  with-  vous  at  all,  or  markedly 

out    marked    hysteria   or  hysterical    or    hypochon- 

hypochondriasis.  driacal. 

4.  Existence  of  arterial  degen-  4.  No  signs  of  arterial  degen- 

eration, eration. 

5.  Existence  of  valvular  dis-    5.  No     discernible     valvular 

ease  of  the  heart.  disease. 

6.  Extension  of    the   pain  to    6.  Heart     sounds    clear    and 

one  or  both  arms.  strong. 

*  See  Walin,  Journ.  cle  Med.  et  Chir.  Prat.  1854.  Also  several 
original   and  quoted  cases  in  Dr.    Handfield    Jones's  "Functional 

Nervous  Disorders,"  second  edition,  1870. 
f  Journ.  de  Med.  et  Chim  Prat.,  July,  1863. 


68  •     ON  NEURALGIA. 

Affirmative  Signs.  Negative  Signs. 

7.  Vivid    sense  of     approach-    7.  Pain    fixed    to     one    spot 
ing  dissolution.  and  increased  or  relieved 

by    muscular  movements 
of    the  pauif ul  parts. 
8.  Pain    running  round   one 
side,    but  not    extending 
to  shoulder  or  arm. 

It  IS  scarcely  necessary  to  say  that  no  single  one  of  the  above 
signs  is  individually  of  positive  worth  for  the  decision,  which 
must  be  made  after  a  careful  review  of  the  comparative  argu- 
ments, pro  and  con.  The  disorders  with  which  anghia  is  most 
likely  to  be  confused  are  (1)  Myalgia  of  the  intercostal  or  pec- 
toral muscles ;  (2)  mtercostal  neuralgia ;  (3)  acute  commencing 
pleurisy.  Either  of  these  may  very  perfectly  simulate  the 
more  formidable  disease,  as  regards  the  two  elements  of  acute 
pain  and  catching  of  the  breath ;  but  the  condition  of  the  ch"- 
culation,  taken  together  with  the  consideration  of  the  above 
named  points,  will  generally  decide  the  question.  Especially 
important  is  the  deep  persuasion  of  impending  dissolution, 
when  present,  as  a  positively  affirmative  symptom. 

It  should  be  born  in  mind  that,  if  we  are  summoned  to  a  pa- 
tient's assistance,  and  have  no  previous  history  to  guide  us,  our 
diagnosis,  to  be  useful,  must  be  ra^oid ;  and  it  is  always  better  to 
err  on  the  side  of  angina  than  in  other  directions,  and  to  employ 
remedies  boldly  in  that  sense,  if  there  be  any  reasonable 
ground  for  believing  tbe  case  to  be  of  that  nature.  A  more 
mature  and  careful  diagnosis  may  be  made  when  the  patient 
has  recovered  from  the  severe  symptoms  of  the  paroxysm. 

Prognosis. — The  prognosis  of  cardiac  neuralgia  is  at  best 
doubtful,  and,  in  many  cases,  positively  bad  in  the  highest  de- 
gree. If  the  attacks  occur  for  the  first  time  in  a  patient  who 
has  passed  middle  life,  and  is  physiologically  old  for  his  age,  i.e., 
shows  tendency  to  degenerative  changes  of  vessels,  arcus  sen- 
ilis, gray  hah"  etc.,  they  are  of  very  gloomy  import;  more  es- 
pecially^ if  any  signs  exist  which  make  a  fatty  change  in  the 
ventricle  probable,  or  if  there  be  serious  valvular  lesions.  The 
probability  here  is  greatly  in  favor  of  a  speedy  fatal  termuiation ; 
if  the  first  attack  does  not  kill,  a  second  or  third  very  probably 
wili ;  at  any  rate,  the  patient  is  not  likely  to  survive  any  con- 
siderable number.  If  the  attack  occurs  in  a  younger  person,  in 
whom  there  is  not  much  likelihood  that  arterial  degeneration 
has  seriously  commenced,  or  the  heart-muscles  become  fatty, 
more  especially  if  the  attacks  liave  been  brought  on  by  such  an 
accidental  circumstance  as  a  very  exhausting  bout  of  ixiental  or 
physical  toil,  then  tliere  is  consideral^le  reason  to  hope  that  the 
disease  may  soon  wear  itself  out.  Even  patients  who  have 
serious  valvular  lesions  may,  with  young  and  undegenerated 
tissues  Ul  then'  favor,  quiet  down  again  into  a  regular  habit  of 


ON  NEURALGIA.  69 

semi-heal  til,  in  which  they  naaj  live  for  a  long  time  without 
any  recurrence  of  cardiac  neuralgia.  The  more  purely  neuro- 
tic form,  again,  especially  when  it  develops  gradually  out  of 
some  pre-existing  chronic  neurosis,  such  as  asthma,  is  usually 
slow  in  its  progress;  and  it  may  well  happen,  in  such  cases, 
that  the  danger  to  life  is  more  on  the  side  of  serious  nervous 
lesions  tlian  from  the  anginal  attacks  themselves.  At  the  same 
time,  it  must  be  remembered  that,  even  in  the  milder  cases, 
any  veiy  luiusual  excitement,  bringing  on  an  unwontedly  se- 
vere attack,  may  produce  fatal  results  at  any  period  of  the 
disease. 

There  is  some  reason  to  believe  that  cardiac  neuralgia  is  oc- 
casionally produced  in  a  reflex  manner  in  consequence  of  a 
severe  existing  intercostal  neuralgia.  I  cannot  say  that  I  have 
witnessed  any  thing  which  can  be  considered  as  completely 
proving  this ;  but  it  certainly  seems  likely  that,  in  some  of  the  few 
cases  of  excessively  painful  herpes  zoster  which  ha^se  proved  fatal 
(of  which  I  have  given  one  example),  cardiac  spasm  or  paraly- 
sis may  have  been  secondarily  induced,  and  may  have  occa- 
sioned the  catastrophe.  It  is  likely  enough  that,  if  this  was 
the  case,  the  reflex  irritation  operated  upon  motor  centres 
which  themselves  were  predisposed  to  take  on  the  morbid 
action ;  but  this  again  is  a  fresh  illustration  of  the  uncertain- 
ties to  v/hich  prognosis  is  liable  in  a  disease  like  angina,  the 
very  fundamental  character  of  which  is  that,  upon  increase  of 
the  irritation,  the  gravity  of  the  resulting  functional  affec- 
tion is  liable  to  be  indefinitely  and  most  rapidly  increased. 

Treatment.- — The  treatment  of  cardiac  neuralgia  is  (1)  pro- 
phylactic, and  (2)  palliative  of  the  attacks. 

As  regards  the  proj^hylactic  treatment,  it  is  unnecessary  to 
repeat  the  remarks  v/hich  we  have  made  elsewhere  upon  the 
general  principles  of  tonic  and  nutritive  medication  in  neural- 
gias of  every  kind.  One  especial  prophj^laxis,  in  the  case  of 
this  formidable  varietj^  of  neuralgia,  is  concerned  with  the 
preservation  of  the  heart  from  certain  disturbing  influences 
wliich  would  render  the  occui'rence  of  the  fit  more  probable. 
All  violent  emotions  and  all  strong  physical  exercise  (but  es- 
pecially such  forms  of  it  as,  like  boating,  are  well  known  to 
"pump"  the  heart  severely)  are  to  be  carefully  avoided.  Even 
indigestion  and  flatulence  are  to  be  carefully  guarded  against 
since  these  are  quite  capable  of  embarrassing  the  action  of  the 
heart  to  a  degree  which,  though  it  might  be  trivial  in  the  case 
of  ordinary  health,  may  prove  fatal  by  exciting  a  flabby  ven- 
tricle to  irregular  and  embarrassing  contraction.  It  is  even 
possible  that  the  strong  irritation  set  up  by  some  varieties  of  in- 
digestible food  might  propagate  an  irritation  to  the  spinal  cord 
which  would  produce  an  interbitoiy  paralj'sis  at  once. 

But  besides  these  .  obvious  precautions  against  mterf erence 
with  the  regular  and  tranquil  action  of  the  heart,  there  are 


70  ON  NEURALGIA. 

some  special  medicinal  remedies  "which  deserve  particular  no- 
tice. Whether  we  really  possess  any  means  of  so  influencing- 
the  nutrition  of  the  muscular  tissue  of  the  heart  as  to  pi'event 
its  lapsing  into  a  fatty  degeneration,  it  is  impossible  to  say; 
but  this  may  be  affirmed  with  some  confidence,  that,  in  cases 
where  awkward  threatenings  of  cardiac  neuralgia  have  occur- 
red, and  simultaneously  it  has  been  noticed  that  the  heart- 
sounds  become  weak  and  the  circulation  languid,  a  most 
marked  improvement  has  been  produced  in  all  respects  by  the 
administration  of  iron  and  strychnia.  I  usually  give  tincture 
of  sesquichloride  of  iron,  ten  minims,  and  strychnia,  one- 
fortieth  of  a  grain,  three  times  a  day.  Still  better,  where  it 
can  be  borne,  is  the  syrup  of  the  triple  phosphate  of  quinine, 
iron,  and  strychnia,  which  undoubtedly  has  an  extraordinary 
influence  upon  tissue  nutrition,  as  exemplified  in  its  remarka- 
ble effects  in  many  cases  of  phthisis.  It  must  be  observed, 
however,  that  it  is  not  every  neuralgic  patient  who  will  bear 
the  combination  of  quinine  with  iron ;  it  has  occurred  to  me  to 
meet  with  several  in  whom  the  union  of  these  two  remedies 
proved  violently  disturbing  to  the  nervous  system,  causing  dis- 
tressing headache  and  palpitation  of  the  heart,  which  could 
not  be  attributed  to  any  want  of  care  in  the  apportioning  of  the 
dose,  or  in  the  mode  of  administration.  Iron  is  more  espec- 
ially indicated,  of  course,  in  cases  where  there  is  ansemia ;  but 
there  are  some  cases  in  which  strychnia  given  alone  seems  to 
produce  a  very  beneficial  inflnence.  {Vide  Chapter  V.,  on 
"  Treatment.") 

By  far  the  most  important  prophylactic  tonic  against  cardiac 
neuralgia,  however,  is  arsenic.  That  this  drug  should  iDrove 
useful  in  cardiac  neuroses  might  readily  be  anticipated  from 
its  very  great  utility  in  many  cases  of  asthma,  a  disease  which, 
as  already  remarked,  has  a  close  relationship  to  the  former. 
Dr.  Philipp  has  recently  recorded  a  case  which  is  perhaps  an  ex- 
treme instance  of  this  beneficial  infiuence  of  arsenic,  but  is 
none  the  less  encouraging,  especially  as  it  only  corroborates 
what  has  been  advanced  by  other  observers.  Given  m  doses  of 
from  three  to  five  minims  of  Fowler's  solution,  twice  or  thrice 
daily,  arsenic  is  an  invaluable  remedy  in  cardiac  neuralgia  ; 
the  one  objection  to  it  being  that  some  neurotic  patients  possess 
such  an  irritable  intestinal  canal  that  the  remedy  cannot  be 
borne,  as  it  produces  diarrhoea.  Even  here  we  may  sometimes 
succeed  by  combming  it  with  very  small  doses  of  opium.  It 
is  more  especially  with  regard  to  those  cases  in  which  the  neu- 
rotic character  of  the  disease  is  very  prominent — i.  e. ,  in  which 
the  nervous  temi^erament  of  the  patient  betrays  itself  in  other 
ways  besides  the  tendency  to  spasmodic  embarrassment  of  the 
heart's  action,  that  arsenic  holds  such  a  very  high  place  as  a 
remedy.  And  it  should  be  carefully  remarked  that  the  pro- 
phylaxis of  angina  extends  itself,  in  such  cases,  beyond  the 


ON  NEURALGIA.  71 

limits  of  actually-declared  and  well-defined  angina,  which  is, 
of  course,  an  uncommon  disease.  This  remedy  is  important, 
and  may  be  most  usefully  employed  in  the  far  larger  group  of 
cases  in  which  a  marked  tendency  to  spasmodic  pain  in  the 
chest,  on  the  occurrence  of  some  comparatively  tiilling  excite- 
ment, is  observed  in  patients  who  either  have  some  oi'ganic 
heart-disease,  or  who  are  liable  to  severe  attacks  of  asthma. 
It  cannot  be  too  often  repeated  that  there  is  no  intelligible  sepa- 
ration, except  one  of  degree,  between  these  cases  and  the  malig- 
nant forms  of  angina.  It  may  be  added  that,  in  my  experi- 
ence, I  have  found  the  whole  group  of  cases  to  be  bound  to- 
gether in  a  smgular  way  l)y  the  tolerance  or  arsenic  which, 
with  certain  exceptions  already  referred  to,  they  display.  Com- 
mencing with  the  small  doses  above  mentioned,  I  have  found 
it  possible,  in  many  cases,  to  advance  to  the  administration  of 
twice  or  thrice  the  quantity,  and  to  continue  this  medica- 
tion for  months  together,  not  only  with  no  evil  effect,  but 
with  the  best  results. 

Of  zinc,  as  a  prophylactic  tonic  in  cardiac  neuralgia,  I 
know  but  little-  Truth  to  say,  it  is  a  nervine  tonic  of  occa- 
sional great  value,  but  which,  on  the  whole,  I  have  found  so 
unreliable  that  I  am  somewhat  prejudiced  against  it;  and  per- 
haps have  not  given  it  a  fair  trial  in  those  milder  cases  of 
cardiac  pain  to  which  it  might  be  suited.  It  does  appear,  how- 
ever, to  have  some  preferential  action  on  the  vagus,  and 
might  therefore  be  possibly  more  useful  than  I  am  at  present 
inclined  to  think  it. 

The  treatment  of  the  acute  neuralgic  stage  itself  is  a  matter 
in  which  we  are  sadly  limited  by  the  exigencies  of  the  case. 
Relief  must  be  excessively  rapid  if  v^e  are  to  save  life  in 
the  most  threatening  cases,  or  to  deliver  the  patient  from  a 
most  prostrating  agony,  which  might  have  lasted  for  hours, 
m  other  instances. 

The  remedy  which  the  highest  authority,  Dr.  Walshe,  seems 
to  put  first  in  eflicacy  is  opium ;  and  he  directs  the  dose  to  be 
measured  by  the  intensity  of  the  pain,  as  much  as  foi'ty  to  sixty 
drops  of  laudanum  being  given  in  a  severe  case.  He  says,  how- 
ever, that  it  should  be  given  with  an  antispasmodic,  such  as 
brandy,  or  ether,  or  sal- volatile  ;  and  I  confess  that  I  believe 
the  antispasmodic  trea^tment  to  be  by  far  the  most  important. 
Indeed,  so  marked  is  the  success  which  I  have  found  to  attend 
the  use  of  ether  in  the  paroxysm,  that  till  lately  I  scarcely 
cared  to  make  further  experiments,  with  drugs,  for  the  relief 
of  the  patient  at  this  stage.  One  teaspoonful  of  ether  in  two 
ounces  of  thickish  mucilage  should  be  given  at  once,  and  re- 
peated in  a  short  time  if  the  patient  does  not  rally. 

In  a  fevf  instances,  angina  seems  to  be  provoked  by  the  irri- 
tation of  indigestible  food,  and  when  there  is  good  reason  to 
suspect  this  an  emetic  should  be  given.    I  strongly  recommend 


72  •       ON  NEURALGIA. 

that  mustard  should  be  used  for  this  purpose,  for  the  effect  of 
a  mustard-emetic  is  by  no  means  merely  to  empty  the  stomach, 
it  has  a  powerfully  rousing  influence  on  the  heart. 

Upon  the  subject  of  the  inhalation  of  chloroform  for  cardiac 
neuralgia,  I  have  only  to  say  that,  though  I  have  seen  it  use- 
fully employed,  I  should  not,  with  my  present  experience, 
ever  think  of  employing  it  myself.  Every  possible  advantage 
which  it  could  give  is  obtained  by  the  internal  use  of  ethei*, 
and  many  serious  dangers  are  avoided,  which  would  attend 
the  use  of  chloroform.  For  it  must  be  remembered  that  the 
only  khid  of  chloroform  mhalation  which  would  be  useful 
would  be  that  in  which  a  carefully  measured  small  dose  of  a 
weakly  impregnated  atmosphere  should  be  inhaled,  and,  with- 
out large  experience  m  the  administration  of  chloroform,  the 
practitioner  will  be  unable  to  secure  this  efi'ect  with  certainty. 
And  the  effect  of  a  powerfully-charged  atmosphere,  breathed 
only  once  or  twice  even,  would  be  instantaneously  fatal. 

Hot  epithems  to  the  ejDigastrium  are  probably  of  some  use, 
and  besides  this  the  temperatxire  of  the  body  should  be  care- 
fully kept  up  by  hot  bottles  to  the  feet,  hot  tins  to  the  epigas- 
trium, etc.  Brandy  should  be  freely  administered  during  the 
attack,  if  we  cannot  immediately  obtain  either  ether  or  a 
remedy  now  to  be  mentioned.  I  refer  to  the  nitrite  of  amyl, 
which,  at  the  time  when  the  first  part  of  this  chapter  was 
written,  I  had  not  had  the  opportunity  of  testing. 

Nitrite  of  amyl  is  a  highly-vaporizable  fluid,  which  pos- 
sesses the  following  remarkable  physiological  action  :  the  m- 
halation  even  of  a  very  small  quantity  is  followed,  after  a 
minute  or  so,  by  a  sudden  acceleration  of  the  heart's  action, 
accompanied  by  intense  crimson  congestion  of  the  vessels  of 
the  face  and  conjunctiva,  and  a  sense  of  enormous  fulness  in 
the  head;  these  phenomena  are  extremely  fugitive,  passing 
away  completely  in  two  or  three  mini;tes,  unless  the  inhalation 
is  renewed.  These  characteristic  effects  had  for  some  years 
been  experimentally  exhibited  by  Dr.  Fraser  and  others,  but 
the  practical  application  of  amyl  to  the  treatment  of  angina 
was  first  suggested,  I  believe,  by  Dr.  Brunton,  in  the  case  of  a 
patient  under  the  treatment  of  Dr.  Maclagon  and  Dr.  Bennett, 
in  the  Edinburgh  Eoyal  Infirmary.  The  angina  was 
in  this  case  symptomatic,  there  being  advanced  valvular 
disease  of  the  heart.  Comparative  examinations  with 
the  sphygmograph,  during  "the  intervals  and  diu-ing  the 
paroxysms,  made  strikingly  manifest  the  fact  that,  during 
the  attacks,  there  was  an  increase  of  arterial  tension  which  was 
directly  proportionate  to  the  severity  of  the  pain  and  cardiac 
embarrassment.  It  was  thus  suggested  to  Dr.  Brunton's  niind 
that  nitrite  of  amyl,  by  relaxmg  the  systemic  arteries,  might 
remove  the  umiatural  tension,  and  give  relief  to  the  pain; 
and  the  result  confirmed  this  hope.     Doses  of  five  and  ten  drops 


ON  NEURALGIA.  73 

were  inhaled  from  a  towel,  with  the  uniforra  result  of  at  once 
quieting  the  pain ;    it  might  return  in  a  few  minutes,  but  a 
second  dose  usually  removed  it  entirely  for  many  hours.     Va- 
rious  other  cases  have  since  been  reported,  in  which  similar 
relief  was  obtained,  and  I  had  occasion  to  employ  it  myself  in 
one  instance.      Tlie  gentleman  whose  case  has  been   related 
above  (see  page  101),  as  an  example  of  the  relief  obtainable  by 
the  use  of  ether  began  to  suffer  rather  more  severely  from  his 
attacks  than  had  beeji  the  case  for  some  time,  toward  the  end 
of  the  year  1869.     I  now  determined  to  try  the  amyl,  and  ac- 
coi'dingly  left  a  small  bottle  containing  half  an  ounce  of  it  in 
his  possession,  with  exact  instructions  to  the  following  effect : 
On  the  first  symptoms  of  a  paroxysm  of  angina,  he  was  to  get 
the  bottle  open,  and  as  soon  as  their  character  was  fully  de- 
clared he  was  to  put  the  bottle  to  one  nostril  (closin"-  the  other 
with  the  finger,  and  keeping  the  mouth   shut)  and  take  one 
long,  powerful  inspiration.     The  result  of  his  first  experiment 
was  very  remarkable :  the  first  sniff  produced,  after  an  interval 
of  a  few  seconds,  the  characteristic  flushing  of  the  face  and 
sense  of  fulness  of  the  head ;  the  heart  gave  one  strong  beat, 
and  then  at  once  he  passed  from  the  state  of  agony  to  one  of 
perfect  repose  and  peace,  and  at  his  usual  bedtime  slept  natu- 
rally.    This  experience  was  repeated  on  several  occasions,  and 
for  a  considerable  time  the  patient  retained  such  full  confidence 
in  the  remedy  that  he  discarded  all  use  of  ether,  and  greatly 
reduced  his  allowance  of  stimulants,  with  very  marked  bene- 
fit to  his  appetite  and  general  health.     The  new  remedy  did 
not  lose  any  of  its  power  by  repetition,  but  unfortunately  the 
patient  at  last  conceived  a  horror  of  it,  which  caused  him  to 
abandon  its  use.     So  distressing  and  alarming  to  him  was  the 
sense  of  fulness  in  the  head  produced  by  the  amyl,  that,  not- 
withstanding his  certain  knowledge  that  he  could  at  once  cut 
short  a  paroxysm,  he  could  not  persuade  himself  to  continue 
its  use,  and  for  some  time  past  he  has  returned  to  the  use  of 
the  ether  and  (though  in  less  quantities  than  previously)  of  the 
brandy,  for  this- purpose.     And  here  it  must  be  remarked  that 
this  objection,  although  probably  needless  in  the  case  of  this 
particular  patient,    may  have  real   importance  m  certain  cir- 
cumstances.     The  admirable  physiological  researches  of  Dr. 
Brunton  leave  no  doubt  that  the  effect  of  inhalation  of  amyl 
is  to  "relax,  very  suddenly,  the   tonic  contraction  of  the  sys- 
temic arteries,  and   in   the  case  of  the  brain  it  would  appear 
that  a  serious  strain  must  be  suddenly  thrown  upon  the  capil- 
lary net-work .     This  being  the   case,  it  appears   likely  that, 
where  the    atheromatous  change   has  considerably  invaded 
these  delicate  vessels,  they  might  prove  too  brittle  to  stand  the 
sudden  distention,    and  a  rupture  and  consequent  cerebral 
hemorrhage   might  ensue.     This  suspicion,  then,  that  such 
pathological  changes  exist,  ought  to  seriously  affect  our  judg- 


74  •     ON  NEURALGIA. 

ment  as  to  the  administration  of  amyl;  and  this  suspicion 
ought  to  be  always  entertained,  prima  facie,  in  the  case  of 
patients  who  have  much  passed  the  age  of  fifty,  more  especially 
if  they  have  gray  hair  and  an  arcus  senilis,  or  if  the  sphygmo- 
graph  yields  a  pulse-trace  of  the  decidedly  square-headed  type, 
or  if  they  have  been  loug  addicted  to  alcoholic  intemperance. 
In  such  patients  I  should  be  disinclined  to  allow  the  use  of 
amyl. 

[Although  I  have  thought  fit  here  to  give  an  outline  of  an- 
gina pectoris  as  a  connected  whole,  I  shall  have  occasion  to 
recur  to  the  subject  again  under  the  heads  of  Pathology  and 
Treatment  of  Neuralgias  in  General.] 

Gastralgia. — Neuralgia  seated  in  the  stomach  itself  is  not  to 
be  distinguished  with  accuracy  from  neuralgic  pains  occupying 
one  or  other  of  the  neighboring  nervous  j)lexuses.  It  must  be 
remembered  that  not  merely  is  the  stomach  itself  copiously 
supplied  by  the  pneumogastric  nerves  with  afferent  filDres,  but 
the  great  solar  plexus  is  close  behind  it,  the  coeliac  i^lexus 
springs  from  the  fore  part  of  the  latter,  and  these,  with  the 
coronary  and  superior  mesentei'ic  plexus,  may  all  be  said  to  be 
well  within  the  region  in  which  ' '  gastralgic  "  isain  is  felt.  It 
is  not  particularly  important,  howei^er,  in  my  opinion,  to 
make  any  very  exact  diagnosis  here,  as  to  the  site  of  the  pain, 
smce  all  these  neuralgias  must  be  considered  to  belong  to  the 
pneumogastric  nerve,  the  branches  supplied  from  vvdiich  are 
probably  the  sole  means  by  which  these  plexuses  become  the 
seat  of  neuralgia. 

Abdominal  pneumogastric  neuralgia  is  an  extremely  dis- 
tressing and  occasionally  a  A^ery  intractable  disorder.  The 
subjects  of  it  are  almost  invai'iably  in  a  state  of  marked  and 
evident  debility,  and  inquiry  generally  elicits  the  fact  that 
they  have  suffered  at  other  times  from  neuralgia  elsewhere 
than  in  its  present  seat.  By  far  the  most  common  history  of 
previous  affections  of  this  kind  is  that  of  trigeminal  neuralgia, 
especially  of  the  supra-orbital  branch;  and  it  has  seve- 
ral times  occurred  to  me  to  observe  the  direct  sequence  of  a 
gastralgia  upon  a  unilateral  browache.  Anaemia  is  a  specially 
frequent  attendant  of  gastralgia,  more  so  than  of  other  neural- 
gias. Women  are,  by  the  general  consent  of  authors,  more 
liable  to  gastralgia  than  men. 

The  special  mark  of  true  neui-algic  pain  in  the  abdominal 
pneumogastric,  as  distinguished  from  other  deep-seated  pains 
in  the  epigastrium,  is  the  remarkably  direct  relation  of  its 
severity  to  the  patient's  exhaustion,  particularly  in  regard  to 
the  weakness  induced  by  want  of  food.  While  the  great  ma- 
jority of  dyspeptic  pains  are  increased  by  filling  the  stomach, 
gastralgia,  on  tlie  contrary,  is  invariably  relieved  by  food, 
often  most  strikingly  and  completely.  Pressure  from  without, 
also,  while  it  aggravates  most  pains  dependent  on  local  organic 


ON  NEURALGIA.  75 

miscliief, nearly  always  more  or  less  relieves  gastralgia.  Equally 
striking  is  the  comfort  given  by  stimulants,  especially  by  Lot 
brandy-and-water ;  in  this  respect  gastralgia  resembles  colic. 
There  is  something  special  in  the  degree  of  mental  depression 
which  attends  gastralgic  paiu.  In  this  it  resembles  the  pains 
of  hypochondriasis,  but  there  is  a  resilience  of  the  spirits 
Avhen  the  i^ain  has  been  relieved  which  is  not  seen  in  the  latter 
affection.  A  very  frequent  complication  of  gastralgia  is 
severe  palpitation  of  the  heart,  but  during  the  paroxysm  itself 
the  pulse,  whether  rapid  or  not,  is  commonly  small,  at  first 
tense,  and  afterward  soft,  but  not  acquiring  any  considerable 
volume  till  the  i)ain  has  ceased. 

So  severe  is  the  pain,  and  so  complete  the  mental  and  physi- 
cal prostration  in  bad  attacks  of  gastralgia,  that  the  first  aspect 
of  the  patient  might  suggest — indeed  often  has  suggested — the 
occurrence  of  gastric  or  duodenal  jperforation ;  but,  as  soon  as 
the  paroxysm  is  over  all  the  alarming  appearances  vanish, 
leaving  only  a  certain  amount  of  tenderness  on  deep  pressure. 
In  the  more  typical  cases  there  are  no  signs  of  dyspepsia 
whatever,  no  fulness  nor  excessive  redness  of  the  tongue,  no 
nausea,  regurgitation  of  food,  nor  pyrosis.  Occasionallj^  the 
neuralgic  aifection  is  complicated  with  more  or  less  gastric 
catarrh ;  but  this  is  a  much  rarer  occurrence,  in  my  experience, 
than  some  writers  would  lead  one  to  believe ;  and,  moreover, 
where  a  certain  amount  of  organic,  disorder  of  the  stomach  is 
observed,  it  is  usually  a  mere  secondary  result  of  the  neural- 
gia. The  most  severe  example  of  gastralgia  which  I  ever  saw 
was  entirely  unaccompanied  by  dyspepsia;  this  patient  abso- 
lutely attempted  suicide  to  escape  from  his  agonizing  pains, 
which  recurred  with  the  greatest  frequency  and  obstinacy,  but 
were  at  last  entirely  removed  by  strychnia.  In  another  patient 
whose  very  interesting  case  will  be  again  alluded  to  under  the 
head  of  Coraplications  of  Neuralgia,  violent  abdominal  pneu- 
mogastric  pain  was  succeeded  by  a  severe  attack  of  trigeminal 
neuralgia,  accompanied  by  inflammation  of  the  eye,  which  in- 
flicted irreparable  damage;  here,  too,  the  gastralgia  was  en- 
tirely uncomplicated  by  any  other  stomach-symptoms. 

Cerebral  Neuralgia. — We  enter,  here,  on  an  extremely  ob- 
scure and  doubtful  subject:  Can  there  be  pain  ni  the  central 
masses  of  the  encephalon?  There  are  undoubtedly  a  not  incon- 
siderable number  of  cases  of  pain,  neuralgic  in  type  on  the 
whole,  in  which  the  suffering  cannot  be  referred  to  any  recog- 
nizable superficial  nerve.  It  seems  deeply  situated  within  the 
cranium.  I  have  also  quoted  cases  of  Dr.  liillier's  in  which 
not  merely  was  there  deep-seated  headache  in  children,  but 
there  was  something  like  a  characteristic  general  change  ob- 
served in  the  brain-tissues  after  death,  viz.,  a  great  moisture 
and  softness  of  texture.  Notwithstanding  all  this,  I  am  not 
convinced,  nor  indeed  much  disposed  to  believe,  that  pain  is 


76  •    ON  NEURALGIA. 

ever  felt  in  the  structure  of  the  brain;  I  rather  believe  that,  in 
the  cases  where  this  seems  to  occur,  the  pain  is  either  in  the  in- 
tracranial portion  of  the  nerve  trunks,  or,  far  more-  x^robably, 
in  the  twigs  of  nerves  that  are  distributed  to  the  cerebral  mem- 
branes. In  that  case  they  are,  strictly  speaking,  only  varieties 
of  neuralgia  of  the  fifth  nerve,  and  might  have  been  properly 
discussed  under  that  heading;  but  it  is  more  convenient  to 
speak  of  them  apart,  since  their  phenomena  present  considera- 
ble differences  from  those  of  the  external  neuralgias  of  the 
head  and  face . 

I  have  now  seen  several  of  these  cases  of  intracranial  neu- 
ralgias, and  very  perplexing  and  (at  fii*st  sight)  alarming  they 
certainly  are .  The  first  of  these  cases  came  under  my  care  in 
1868.  The  patient  was  a  single  lady  who  had  greatly  over- 
tasked an  intellect  that  was  not,  perhaps,  originally  very 
strong,  by  trying  to  do  hack  literature  on  conscientious  prin- 
ciples; insisting,  for  instance,  on  knowing  something  about 
every  subject  she  wrote  upon.  Her  age  was  thirty-eight  when 
she  applied  to  me ;  menstruation  was  scanty  but  regular ;  and, 
on  the  whole,  she  could  not  be  said  to  have  passed  an  unhealthy 
life,  although  "nervous-headaches"  and  "sick-headaches" 
had  occasionally  beset  her.  This  time  the  trouble  seemed  to  be 
more  serious.  Ten  days  before  applying  to  me,  she  had  awaked 
in  the  morning  with  a  feeling  that  something  was  very  wrong- 
in  her  head ;  there  was  not  so  much  pain  as  a  dull,  brooding 
sort  of  weight,  felt  deeply  within  the  cranium,  and  rather  an- 
terioi-ly.  This  had  not  lasted  many  hours  when  she  was  seized 
Tv^ith  a  sensation  of  intense  cold,  amounting  almost  to  rigors, 
and  then  before  long  was  suddenly  attacked  with  acute  split- 
ting pain  in  the  same  situation  as  the  feeling  of  weight  already 
mentioned  had  occupied.  This  pain,  which  came  and  went,  or 
rather  intensified  and  remitted,  without  ever  completely  ceas- 
ing, lasted  about  two  hours,  and  then  rather  suddenly  disap- 
peared, leaving  the  patient  with  a  deep  "  bruised  and  sore  feel- 
ing in  her  brains."  The  pain  recurred  about  the  middle  of  the 
next  day,  lastmg  for  several  hours,  and  again  leaving  behind  it 
the  sore  feeling.  Day  by  day  the  paroxysms  returned,  and,  en 
the  day  before  her  visit  to  me,  the  patient  had,  she  told  me, 
been  diiven  frantic  by  her  sufferings  and  had  become  actually 
delirious.  Her  appearance,  when  I  first  saw  her,  was  wretched ; 
the  face  haggard,  both  eyes  sunken  and  surrounded  with  deep 
rings  of  dusky  pigment,  both  conjunctivae  bloodshot,  the  whole 
face  almost  earthy  in  its  pallor.  At  that  hour  (11  A.  M.)  the 
pain  had  not  iDositively  recommenced,  but  she  was  in  momen- 
tary dread  of  its  recurrence.  She  complained  of  giddiness, 
muscse  volitantes,  and  great  feebleness  of  vision,  and  dreaded 
attempting  to  read,  as  the  mere  effort  of  fixing  her  eyes  on 
anything  intently  caused  flashes  of  fire  before  them.  It  was 
difficult  at  first  to  believe  that  there  was  not  some  serious  or- 


ON  NEURALGIA.  77 

ganic  brain -mischief ;  but  on  the  whole  I  concluded  that  there 
was  an  absence  of  any  genuine  synaptonis  of  such  disease.  At 
the  same  time,  the  pain  was  decidedly  not  referred  to  any  cu- 
taneous sensory  nerve ;  and  on  tlie  whole  it  api>eared  probable 
that  the  affection  was  intracranial.  There  remained  tlie  diag- 
nosis of  meningeal  neuralgia,  and  to  tliis  I  provisionally  made 
up  my  mind.  The  opinion  that  the  pain  did  not  depend  an  any 
fixed  organic  disease  was  decisively  justified  by  the  i^esults  of 
treatment.  One-sixth  of  a  grain  of  morphia  was  injected  on 
the  occasion  of  the  first  visit,  and  this  was  repeated  every  day, 
and  sometimes  twice  a  day,  for  a  fortnight ;  by  this  sole  means, 
with  rest,  quietude,  and  light  noLirishing  food,  the  patient  was 
brought  to  comparative  convalescence.  The  injections  were 
then  gradually  discontinued,  and  she  got  quite  well . 

In  a  second  case,  which  presented  itself  in  the  out-patient 
room  at  Westminster  Hospital,  a  young  man  of  markedly- 
nervous  temj)erament,  who  had  been  somewhat  given  to  drink, 
compkined  of  similarly  deep-seated  intermittent  pain,  which 
he  referred,  however,  to  a  point  nearer  the  back  of  the  head. 
He  suffered,  also,  from  vertigo,  especially  after  unusually  long 
paroxysms.  Blisters  to  the  nape  of  the  neck,  and  a  few  subcu- 
taneous injections  of  morphia,  removed  the  pain  and  the  ver- 
tigo completely. 

A  third  example  was  that  of  a  gentleman,  aged  thirty-four, 
who  was  sent  over  from  the  neighborhood  of  Sydney,  Austra- 
lia, to  see  me.  Here,  also,  there  was  deep-seated  intracranial 
neuralgic  pain  of  the  most  severe  kind,  which  greatly  alarmed 
his  local  medical  attendants ;  and  it  was  only  after  a  great 
many  remedies  had  been  tried  that  one  medical  man  gave  the 
opinion  that  the  disease  was  ' '  neuralgia  of  tlie  membranes  of 
the  brain,"  and  employed  the  hypodermic  injection  of  mor- 
phia. This  treatment  at  once  gave  great  relief,  though  the  pain 
had  been  so  severe  as  to  cause  delirium  on  several  occasions. 
In  order  to  get  thoroughly  re-established,  he  was  sent  to  Eng- 
land, and  desired  to  consult  me.  As  was  expected,  the  voyage 
proved  of  the  greatest  service,  as  he  hardly  suffered  at  all 
while  on  the  water.  On  arriving  in  England  he  was  at  first 
well,  but  in  a  week  or  two  began  to  feel  somewhat  below  par, 
and  one  morning,  feeling  an  attack  of  pain  coming  on,  he 
came  to  me.  He  was  a  tall  and  strongly-built  man,  with  noth- 
ing peculiar  in  his  appearance  except  a  certain  languor  and 
heaviness  of  the  eyes.  He  appeai'ecl  to  have  lived  somewhat 
freely  and  to  have  smoked  decidedly  to  excess.  His  descrip- 
tion of  the  attacks  left  no  doubt  of  their  neuralgic  character, 
and  in  otlier  respects  they  seemed  quite  analogous  to  tlie  other 
cases  mentioned  above,  except  in  one  thing,  that  there  seemed 
a  good  deal  of  evidence  tending  to  show  a  bad  local  influence 
in  the  air  of  that  part  of  Australia  where  he  usually  resided. 
Almost  any  change  from  that  had  always  done  him  good, 


78  ON  NEURALGIA. 

thougn  nothing  had  done  anything  Hke  so  much  as  the  voyage 
to  England.  On  the  occasion  of  his  first  visit  to  me  I  injected 
him  with  one-sixth  gi'ain  acetate  of  morphia,  thereby  stopping 
the  pain.  I  prescribed  muriate  of  iron  and  minute  doses  of 
strychnia,  which  he  took  for  some  little  time,  but  the  pain 
never  recurred  during  his  stay  in  England  and  on  the  Conti- 
nent. Unfortunately,  as  he  was  anxious  to  return  to  Austra- 
lia, I  permitted  him  to  do  so,  after  a  stay  in  the  Old  World  of 
only  three  or  four  months ;  but,  very  shortly  indeed  after  his 
return  to  Sydney,  his  old  complamt  attacked  him.  This  time, 
unhappily,  the  hypodermic  morphia  has  proved  merely  pallia- 
tive, and  I  have  latterly  heard  very  bad  accounts  from  him ; 
still,  there  has  been  nothmg  to  throw  doubt  on  the  neuralgic 
character  of  the  disease. 

In  reflecting  upon  the  anatomy  of  the  nervous  branches  to 
the  dura  mater,  I  have  formed  the  opinion  that  there  are  two 
situations,  one  anterior  and  the  other  posterior,  in  which  intra- 
cranial neuralgia  may  occur ;  the  former  at  the  giving  off  of 
Arnold's  recurrent  branch  from  the  ophthalmic  division,  near 
the  sella  turcica,  the  other  in  the  peripheral  twigs  of  this  same 
branch,  distributed  to  the  tentorium  cerebelli. 

Pharyngeal  Neuralgia. — A  rather  comm.on  and  extremely 
troublesome  form  of  neuralgia  is  that  v/hich  attacks  the 
pharynx.  It  is  very  much  more  common  in  women  than  in 
men,  and  especially  in  hysterical  persons.  The  pain  com- 
monly commences  in  a  not  very  acute  manner ;  it  may  be  felt 
for  some  days,  or  even  weeks,  as  a  dull  aching,  coming  and 
going  pretty  much  in  accordance  with  the  patient's  state  of 
fatigue,  or  of  reinvigoration  after  meals,  etc.  Some  trivial 
circumstance,  such  as  a  slightly  extra  degree  of  exhaustion,  or 
the  influence  of  some  depressing  emotion,  will  then  change  the 
type  to  that  of  decided  neuralgia,  which  may  become  extremely 
severe.  Nothing  is  more  annoying,  and  even  distressing, 
than  the  suff^ering  itself,  besides  which  there  are  abnormal  sen- 
sations in  the  throat  which  almost  irresistibly  compel  the 
patient  to  believe  that  there  are  severe  inflammation  and 
iilceration,  and  that  the  throat  is  in  danger  of  being  closed  up. 
Although  the  pain  is  usually  one-sided,  it  sometimes  affects 
both  sides,  and  is  felt  also  at  the  back  of  the  pharynx.  The 
act  of  swallowing  being  painful,  there  is  the  greater  suspicion 
of  inflammation  or  ulceration,  but  careful  observation  shows 
that  a  large  bolus  of  food  is  swallowed  with  as  little,  if  not  less, 
pain  than  a  small  mouthful  of  solids  or  even  liquids. 

Pharyngeal  neuralgia  must,  I  think,  be  considered  mainly 
an  affection  of  the  glosso-pharyngeal  nerve;  the  evidence  for 
this  is  found  in  the  distribution  of  the  pain.  A  slight  degree 
of  the  neuralgia  will  only  involve  some  one  or  two  points  m  or 
behind  the  tonsil;  but,  when  the  pain  is  strongly  developed,  it 
will  be  found  to  radiate  into  the  tongue,  in  one  direction,  and 


ON  NEURALGIA.  79 

into  the  neck  (following  the  course  of  the  carotid)  in  another, 
besides  spreading  well  into  the  region  occupied  by  the  pharyn- 
geal plexus.  One  disagreeable  rehex  effect  of  severe  pliaiyn- 
geal  neuralgia  consists  in  involuntary  movements  of  the 
muscles  of  deglutition,  another  is  seen  in  the  copious  outpour- 
ing of  thick  mucus  similar  to  that  which  collects  in  the 
pharynx  and  oesophagus  when  a  foreign  substance  has  become 
impacted. 

Laryngeal  neuralgia  concentrates  itself  mainly  in  the  twigs 
of  the  superior  laryngeal  branch  of  the  pneumogastric  which 
are  distributed  to  the  arytseno-epiglottidean  folds,  the  epiglottis, 
and  the  chordas  vocales ;  more  rarely  a  neuralgia  is  developed 
lower  down,  within  the  cavity  of  the  larynx,  apparently  ni 
one  or  more  of  the  scanty  twigs  to  the  mucous  membrane  sup- 
plied by  the  recun^ent  laryngeal. 

Pure  neuralgias  of  the  larynx,  like  those  of  the  pharynx,  are 
more  common  in  women,  and  especially  in  weakly  hysterical 
women,  than  in  men.  They  are  easily  excited  and  greatly 
aggravated  by  movements  of  the  parts,  and  thus  it  happens 
that,  among  men,  by  far  the  most  numerous  subjects  of  laryn- 
geal neuralgia  are  found  among  clergymen,  professional 
singers,  and  others  whose  occupation  compels  them  to  strenu- 
ous and  fatiguing  employment  of  the  laryngeal  muscles.  It  is 
rather  a  singular  and  striking  fact,  however,  that  the  so-called 
"  clei'gjanan's  sore-throat,"  which  is  characterized  by  most  un- 
pleasant sensations,  and  by  a  more  or  less  complete  loss  of 
voice,  is  not,  in  the  majority  of  cases,  attended  with  any  dis- 
tinct laryngeal  neuralgia.  It  seems  that  a  predisposition  to 
neuralgia  is  a  necessary  element  in  the  latter  affection. 


CHAPTER    II. 

COMPLICATIONS  OF    NEURALGIA. 

The  secondary  affections  which  may  arise  as  complications 
of  neuralgia  form  a  deeply  interesting  chapter  in  nervous 
pathology,  and  one  which  has  only  been  explored  in  quite 
recent  years.  The  excellent  treatises  of  Valleix  and  Romberg, 
written  only  thirty  years  ago,  make  but  most  cursory  and 
superficial  mention  of  these  complications,  and  do  not  attempt 
to  group  them  in  a  scientific  manner.  The  reflex  convulsive 
movement  of  the  facial  muscles  in  severe  tic-douloureux  had 
of  course  been  long  observed ;  and  Valleix  added  the  correct 
observation  that  gastric  disturbance  was  often  secondarily  pro- 
voked in  facial  neuralgia,  thus  improving  greatly  on  the  old 
view,  which  supposed  that,  where  trigeminal  neuralgia  and 


80  COMPLICATIONS  OF  NEURALGIA. 

Stomach  disorder  coexisted,  tlie  latter  must  liave  been  the  ante- 
cedent and  the  cause  of  the  former,  Still,  he  did  not  explain 
the  pathological  connection.  And  as  regards  certain  other 
most  interesting  results  of  neuralgia,  which  he  could  not  avoid 
meeting  with  from  time  to  time,  e.  g. ,  lachrymation,  flux  from 
the  nostril,  salivation,  altered  nutrition  of  the  hair,  he  only 
speaks  of  these  as  occasional  phenomena,  and  in  no  way 
classifies  them,  or  explains  their  relation  to  the  neuralgia  itself. 

There  did  exist,  however,  one  too  little  known  work  of  some 
years  earlier  date,  which,  though  not  dealing  specifically  with 
neuralgia,  and  though  based  upon  the  necessarily  very  imper- 
fect knowledge  of  the  functions  of  the  nervous  system  preva- 
lent in  its  day,  had  nevertheless  done  much  to  lay  the  founda- 
tion of  a  comprehensive  view  of  the  complications  of  neuralgia; 
we  refer  to  the  work  of  the  brothers  Grihn,  on  ' '  Functional 
Affections  of  the  Spinal  Cord  and  Ganglionic  System,"  pub- 
lished in  1834.  In  this  most  interesting  treatise,  the  record  of 
acute  and  extensive  observations  made  in  a  quiet  and  unpre- 
tending way  by  two  Irish  practitioners,  numerous  examples  are 
cited  in  which  neuralgic  affections  were  seen  to  be  inseparably 
united  with  secondary  affections  of  tlie  most  various  oi'gans, 
with  which  the  neuralgic  nerves  could  have  no  connection  ex- 
cept through  the  centres,  by  reflex  action.  The  authors,  while 
firmly  grasping  the  fact  of  the  common  connection  of  the 
nerve-pain  and  the  other  phenomena  (convulsions,  paralysis, 
altered  special  sensation,  changes  in  secretion,  changes  even  in 
the  nutrition  of  particrdar  tissues)  with  the  central  nerve  sys- 
tem, were  doubtless  in  error  in  thinking  that  they  could  detect 
the  precise  seat  of  the  origiiial  m.alady,  by  discoveiing  certain 
points  of  tenderness  over  the  spinal  column .  But  their  facts  were 
observed  with  the  greatest  care,  and  can  now  be  interpreted 
more  intelligently  than  was  possible  at  the  time.  _  Here,  for 
example,  is  a  case  which  forestalls  one  of  the  most  interesting 
pieces  of  information  which  more  recent  research  has  made 
generally  known : 

"Case  XXIV. — Kitty  Hanley,  aged  fourteen  years,  cata- 
menia  never  appeared ;  about  six  months  ago  was  attacked 
with  pain  in  the  right  eye  and  brow,  occurring  only  at  night, 
and  then  so  violently  as  to  make  her  scream  out  and  disturb 
every  one  in  the  house ;  it  afterward  occurred  in  the  infra- 
orbital nerve,  and  along  the  lower  jaw  in  the  teeth,  and  there 
was  inflammation  of  the  cornea,  with  superficial  ulceration 
and  slight  muddiness.  Tenderness  was  found  at  the  upper 
cervical  vertebras,  pressure  on  any  of  them  exciting  severe 
pain  in  the  vertex  and  brow ;  but  none  in  the  eye  or  jaws, 
where  it  is  never  felt  except  at  night." 

The  above  is  a  well-marked  example  of  neuralgia  of  the 
trigeminus  causing  secondary  inflammation  and  ulceration  of 
the  eye  of  a  precisely  similar  kind  to  that  which  had  been  ex- 


COMPLICATIONS  OF  NEURALGIA.  81 

perimentally  produced  by  Magendie  by  section  of  the  fifth,  at 
or  posterior  to  its  Gasserian  ganghoii.  We  shall  see,  hereafter, 
how  extremely  important  are  this  and  similar  facts,  not  only 
in  regard  to  the  clinical  history,  but  also  to  the  pathology  of 
neuralgia  in  general. 

The  lirst  regular  attempt,  I  believe,  to  classify  the  complica- 
tions of  neuralgia,  was  made  by  M.  Notta,  in  a  series  of  elabo- 
rate papers  in  the  "Archives  Generales  de  Medecine  "  for  1854. 
We  may  specially  mention  his  analysis  of  a  hundred  and 
twenty-eight  cases  of  trigeminal  neuralgia,  which  is  well  fitted 
to  impress  on  the  mind  the  frequency,  though,  as  we  shall 
presently  see,  it  does  not  adequately  represent  the  seriousness, 
of  these  secondary  disorders.  As  regards  special  senses,  Notta 
says  that  the  retnia  was  completely  or  almost  completely  ]3ara- 
lyzed  in  ten  cases,  and  in  nine  others  vision  was  interfered 
with,  partly,  i^robably,  from  in] paired  function  of  the  retina, 
but  partly,  also,  from  dilatation  of  the  pupil  or  other  functional 
derangement  independent  of  the  optic  nerve.  The  sense  of 
hearing  was  injpaired  in  four  cases.  The  sense  of  taste  was 
prevertedin  one  case,  and  abolished  in  another.  As  regards 
secretion,  lachrymation  was  observed  in  sixty-one  cases,  or 
nearly  half  the  total  number.  Nasal  secretion  was  repressed 
in  one  case,  in  ten  others  it  was  increased  on  the  affected  side. 
Unilateral  sweating  is  spoken  of  more  doubtfully,  but  is  said 
to  have  been  probably  present  in  a  considerable  number  of 
cases.  In  eiglat  instances  there  was  decided  unilateral  redness 
of  the  face,  and  five  times  this  was  attended  with  noticeable 
tumefaction.  In  one  case  the  unilateral  tumefaction  and  red- 
ness persisted,  and  were,  in  fact,  accompanied  by  a  genei'al 
hypertrophy  of  the  tissues.  Dilatation  of  the  conjunctival 
vessels  was  observed  in  thirty-four  cases.  Nutrition  was 
affected  as  follows :  In  four  cases  there  vvas  unilateral  hyper- 
trophy of  the  tissues ;  in  two,  the  hair  was  hypertrophied  at 
the  ends,  and  in  several  others  it  Vv^as  observed  to  fall  out  or  to 
turn  gray.  The  tongue  Vv^as  greatly  tumefied  in  one  case. 
Muscular  contractions,  on  the  afi'ected  side,  were  noted  iw  fifty- 
two  cases.  Permanent  tonic  spasm,  not  due  to  photophobia, 
was  observed  in  the  eyelid  in  four  cases,  in  the  muscles  of 
mastication  four  times,  in  the  muscles  of  the  external  ear  once. 
Paralysis  affected  the  motor  oculi,  causing  prolapse  of  the 
upper  eyelid,  in  six  cases;  in  half  of  these  there  was  also  out- 
ward squint.  In  two  instances  the  facial  nmscles  were  para- 
lyzed in  a  iDurely  reflex  manner.  The  pupil  was  dilated  in 
three  cases,  and  contracted  in  two  others,  without  any  impair- 
ment of  sight;  in  three  others  it  was  dilated,  with  considerable 
diminution  of  the  visual  power.  Finally,  with  regard  to  com- 
mon sensibility,  M.  Notta  reports  three  cases  in  which  anaes- 
thesia was  observed.  HyperaE'sthesia  of  the  sui-face  only  oc- 
curred in  the  latter  stages  of  the  disease. 


82  COMPLICATIONS  OF  NEURALGIA. 

To  Notta's  list  of  complications  of  trig-eininal  neuralgia  must 
be  added  the  following,  all  of  which  have  been  witnessed,  and 
several  of  them  in  a  large  number  of  instances:  Iritis,  glau- 
coma, corneal  clouding,  and  even  ulceration;  periostitis, 
unilateral  furring  of  the  tongue,  herpes  unilateralis,  etc.  In 
writing  on  this  subjt^ct  three  or -four  years  ago,  I  mentioned 
tliat  all  these  secondary  affections  had  been  seen  by  myself, 
except  glaucoma.  That  is  now  no  longer  an  exception ;  indeed, 
my  attention  has  been  so  forcibly  called  to  the  connection  be- 
tween glaucoma  and  facial  neuralgia,  that  I  shall  presently 
examine  it  at  some  length. 

Tlie  trigeminus  is,  of  all  nerves  in  the  body,  that  one  whose 
affections  are  likely  to  cause  secondary  disturbances  of  wide 
extent  and  various  nature,  owing  to  its  large  peripheral  ex- 
panse, the  complex  nature  of  its  functions,  and  its  extensive 
and  close  connections  with  other  nerves.  Moreover,  its  rela- 
tions to  so  important  and  noticeable  an  organ  as  the  eye  tends 
to  call  our  attention  strongly  to  the  phenomena  that  attend  its 
]jerturbations.  But  there  is  every  reason  to  think  that  all 
secondary  complica  ions  which  may  attend  trigeminal  neuralgia 
are  represented  by  analogous  secondary  affections  in  neuralgias 
in  all  kinds  of  situations ;  and  we  may  classify  them  in  the 
principal  groups  which  correspond  to  disturbance  of  large  sets 
of  functions: 

1.  First,  and  on  the  whole,  probably,  the  most  common  of 
all  secondary  affections,  we  may  rank  some  degree  of  vaso- 
motor paralysis.  It  may  be  doubted  if  neuralgia  ever  reaches 
more  than  a  very  slight  degree  without  involving  more  or  less 
of  this ;  for  so-called  points  douloureux  are  themselves  pretty 
certainly,  for  the  most  part,  a  phenomenon  of  vaso-motor 
palsy ;  and  the  more  widely-diffused  soreness,  such  as  remains 
in  the  scalp,  for  instance,  after  attacks  of  pain,  even  at  an 
earlier  stage  of  trigeminal  neuralgia,  than  that  in  which  per- 
manenently  tender  points  are  formed,  is  probably  entirely  due 
to  a  temporary  skin-congestion.  The  phenomenon  j^resents 
itself  in  a  much  more  striking  way  in  the  condition  of  the 
conjunctiva  seen  in  mteiise  attacks  of  neuralgia  affecting  the 
ocular  and  peri-ocular  branches  of  the  fifth ;  one  sometimes 
finds  the  whole  conjunctiva  deeply  crimson ;  and,  in  one  re- 
markable instance  that  I  observed,  the  same  shade  of  intense 
red  colored  the  mucous  membrane  of  the  nostril  of  the  same 
side.  In  several  instances,  I  have  seen  a  more  than  usually 
violent  attack  of  sciatic  pain  followed  by  tlie  development  of 
a  pale,  rosy  blush  over  the  thinner  parts  of  the  skin  of  the  leg, 
especially  of  the  calf,  which  were  then  extremely  tender,  in  a 
diffuse  manner,  for  some  time  after  spontaneous  pain  had 
ceased. 

2.  Not  merely  the  circulation,  however,  but  the  nutrition  of 
tissues,  becomes  positively  affected,  in  a  (considerable  number 


COMPLICATIONS  OF  NEURALGIA.  83 

of  cases.  It  is  difficult  to  judge,  with  any  exactness,  in  what 
proportion  of  neuralgic  cases  this  occurs,  but  its  slighter  de- 
grees must  be  very  common.  It  has  very  frequently  happened 
to  me,  quite  accidentally,  in  examining  with  some  care  the 
fixed  painful  points,  which  are  so  important  in  diagnosis,  to  be 
struck  with  the  decided  evidence  to  the  finger  of  solid  thicken- 
ing, evidently  dependent  on  hypertrophic  development  of 
tissue-elements;  in  sevei-e  aiid  long-standing  cases,  I  believe 
this  condition  will  always  be  found.  Probablythe  change  is, 
more  usually  than  not,  sub-inflanunatory ;  but  it  is  certain,  on 
the  other  hand,  that  there  are  great  variations  in  the  kind  of 
tissue-changes  complicating  neuralgia,  and  that  inflammation 
is  no  necessary  element  in  them.  This  subject  has  greatly 
engaged  my  attention,  and  I  find  myself  able  to  give  what  is 
probably  a  fuller  account  of  the  matter  than  any  yet  published 
connectedly. 

The  following  tissues  have  been  seen  by  myself  to  become 
altered  under  the  influence  of  neuralgia  in  nerves  distributed 
to  them,  or  to  the  parts  in  their  immediate  neighborhood. 

(a)  The  hair  has  changed  in  color  in  many  cases.  Of  twenty- 
seven  jDatients  suffering  from  neuralgia  of  the  ophthalmic 
division  of  the  flfth,  eleven  had  more  or  less  decided  localized 
grayness  of  hair  on  that  side.  The  amount  of  this  varied 
greatly,  from  mere  patches  of  gray  near  the  roots  of  the  hair 
to  decided  grayness  of  the  majority  of  the  hairs  over  the  larger 
part  of  half  the  head,  nearly  to  the  vertex;  but  in  each 
case  it  was  a  change  of  color  that  did  not  exist  on  the 
other  side  of  the  head.  In  four  of  these  cases  there  was 
also  grayness  of  part  of  the  eyebrow  on  the  affected  side. 
A  very  remarkable  phenomenon,  which  I  have  sometimes 
identified,  is  fluctuation  of  the  color,  the  grayness  notably  in- 
creasing during,  and  for  some  time  after,  an  acute  attack  of 
pain,  and  the  same  hairs  returning  afterward  more  or  less  to 
their  original  color.  My  attention  was  first  called  to  this 
curious  occurrence  m  my  own  case.  I  have  so  often  related 
this  case  [see,  for  instance,  my  article  on  Neuralgia  in  ' '  Rey- 
nolds's System  of  Medicine, "  vol.  ii.]  that  I  shall  merely  re- 
call the  fact  that,  when  pain  attacks  me  severely,  the  hair  of 
the  eyebrow  on  the  affected  side  displays  a  very  distinct  patch 
of  gray  (on  some  occasions  it  has  been  quite  white)  opposite 
the  tissue  of  the  supra-orbital  nerve,  and  that  the  same  hairs 
(which  can  be  easily  identified)  return  almost  to  the  natural 
color  when  I  am  free  from  neuralgia.  I  must,  hoAvever,  add 
the  very  curious  fact,  which  I  observed  accidentally  in  ex- 
perimenting (as  regards  urinary  elimination)  on  the  effects  of 
large  doses  of  alcohol,  that  a  dose  sufficiently  large  to  produce 
uncomfortably  narcotic  effects  invariably  caused  the  same  tem- 
porary change  of  color  in  the  hair  of  the  same  eyebrov/,  even 
when  no  decided  pam  was  produced,  but  only  general  malaise. 


84  COMPLICATIONS  OF  NEURALGIA. 

The  subject  will  be  again  referred  to  under  the  heading  of 
Pathology. 

Change  in  the  size  and  texture  of  the  hairs,  in  neuralgia,  has 
been  noted  by  Romberg  and  Notta,  and  has  been  several  times 
observed  by  myself.  Occasionally  the  individual  hairs  near 
the  distribution  of  the  painful  nerve  becomes  coarsely  hyjier- 
trophied;  at  times  the  number  of  hairs  appears  to  multiply, 
but  I  imagine  this  is  only  a  case  of  more  rapid  and  exuberant 
development  of  hairs  that  would  be  otherwise  weak  and  small. 
In  one  very  remarkable  instance  of  sciatica  this  came  under 
my  observation ;  the  whole  front  of  the  painful  leg,  froni  the 
knee  nearly  to  the  ankle,  became  clothed,  in  the  course  of 
about  six  months,  with  a  dense  fell  of  hair,  which  strongly 
reminded  me  of  similar  abnormal  hair  growths  that  have  been 
occasionally  seen  in  connection  with  traumatic  injuries  to  the 
s^Dinal  cord.  More  commonly,  the  effect  of  neuralgia  upon 
hair  is  to  make  it  brittle,  and  to  cause  it  to  fall  out  in  con- 
siderable quantities;  one  young  lady,  who  consulted  me  for  a 
severe  migraine,  was  seriously  afraid  of  having  a  good  head  of 
hair  completely  ruined  in  this  way,  but  the  hair  gradually  grew 
again  after  the  neuralgia  had  disappeared. 

(6)  The  periosteiim  of  bone  and  the  fibrous  fasciae  in  the 
neighborhood  of  the  painful  points  of  neuralgic  nerves  not  un- 
frequentlv  take  on  a  condition  of  sub-acute  inflammation,  with 
marked  thickening  and  tenderness  on  pressure.  The  most 
striking  instance  of  this  that  I  have  seen  was  in  a  lady  suffer- 
ing from  severe  cervico-brachial  neuralgia.  In  the  neighbor- 
hood of  the  emergence  of  the  musculo  spiral  nerve  at  the  outer 
side  of  the  arm,  there  was  developed  what  looked  for  all  the 
world  like  a  large  syphilitic  node,  except  that  the  skin  was 
brightly  reddened  over  it;  this  disappeared  altogether  some 
little  time  after  the  neuralgia  had  been  relieved  by  ordinary 
treatment.  I  must  say  that,  but  for  the  peculiar  circumstances 
of  the  case,  putting  syphilis  out  of  the  question,  I  could  not 
have  avoided  the  suspicion,  at  first,  that  the  swelling  was  spe- 
cific. But  I  have  several  times  seen  similar,  though  less 
developed,  swellings  in  neuralgia,  and  in  one  case  I  noticed 
the  occurrence  of  such  a  swelling  on  the  malar  bone,  in  an  old 
woman  in  whom  the  neuralgic  pam  was  limited  to  the  auriculo- 
temporal and  the  supra-orbital  branches  of  the  fifth. 

A  very  important  point  is  to  be  noted  in  connection  with 
these  sub-inflammatory  swellings  in  connection  wdth  neural- 
gia. Pressure  on  them  will,  frequently,  not  merely  excite  the 
neuralgic  pains  in  the  branches  of  the  affected  nerve,  but  send 
a  powerful  reflex  influence  through  the  cord  to  distant  organs, 
causing  vomiting,  for  instance,  or  affecting  the  action  of  the 
heart  in  a  very  perceptible  manner.  I  shall  show,  when  I  come 
to  speak  of  the  phenomena  of  so-called  spinal  irritation,  that 
this  circumstance  has  led  to  erroneous  influences  in  many 


COMPLICATIONS  OF  NEURALGIA.  85 

cases.  These  exquisitely  tender  points  are  often  found  where 
Trousseau  places  his  neuralgic  point  ajjophysaire,  namely, 
over,  or  very  near,  the  spinous  processes  of  the  vertebrae.  The 
tenderness  is  quite  unlike  that  which  is  known  as  hysterical 
hypera3sthesia ;  it  is  much  severer,  and  is  limited  to  one,  two, 
or  tliree  points,  corresponding,  in  fact,  to  the  suj)erficial  part 
of  tlie  posterior  branches  of  as  many  spinal  nerves. 

(c)  Tiie  nutrition  of  the  skin  over  neuralgic  nerves  is  some- 
times notably  affected  even  when  the  process  does  not  reach 
the  truly  inflammatory  stage,  which  will  be  more  particularly 
mentioned  presently.  A  certain  coarseness  of  texture  of  the 
skin  has  struck  me  much,  in  several  cases  of  long-standing 
facial  neuralgia.  And  there  is  a  most  curious  phenomenon 
(which  will  be  especially  considered  hereafter  in  regard  to  the 
singular  influence  of  the  constant  galvanic  current  upon  it), 
the  distribution  of  a  greater  or  less  amount  of  dark  pigment  to 
the  skin  near  the  painful  part.-  This  phenomenon  is  much 
more  marked  during  the  paroxysms,  and  in  the  slighter  cases 
entirely  disappears  in  the  intervals,  but  m  old-standing  severe 
cases  it  becomes  more  or  less  permanent. 

(d)  The  mucous  membranes,  in  situations  whei'e  we  can  ob- 
serve them,  not  unfrequently  show  interesting  changes,  the 
nutrition  of  the  epithelium  of  parts  covering  the  painful  nerve 
being  exaggerated.  It  has  been  noted  by  various  observers, 
in  neuralgia  affecting  the  second  and  third  divisions  of  the 
trigeminus,  that  the  half  of  the  tongue  corresponding  to  the 
painful  nerve  was  covered  with  a  dense  fur.  This  is  by  no 
means  universally  the  case,  but  I  have  seen  it  occur  several 
times.  In  my  own  case,  in  which  the  neuralgia  is  limited  for 
the  most  part  to  the  opthalmic  division,  and  only  rarely  spreads 
even  to  the  second  division  of  the  nerve,  this  does  not  usually 
occur,  but  I  have  noticed  it  on  one  or  two  occasions.  And  I 
once  made  the  still  more  singular  observation  that  a  large 
narcotic  dose  of  alcohol,  which  was  sufficient  to  cause  com- 
paratively free  elimination  of  unchanged  alcohol  in  the  urine, 
caused  furring  of  the  tongue,  which  was  decidedly  thicker 
on  the  side  of  the  affected  nerve  than  on  the  other  half  of  the 
tongue. 

(e)  We  come  now  to  a  group  of  complications  of  neuralgia 
which  are  exceedingly  important,  and  by  no  means  adequately 
appreciated  as  yet,  viz. ,  the  acute  inflammations  which  directly 
result  from  neuralgic  affections  in  a  certain  percentage  of  cases, 
IDrobably  much  larger  than  has  been  at  all  generally  suspected. 

The  most  familiar  of  the  inflammatory  complications  of 
neuralgia  is  herpes  zoster,  the  favorite  seat  of  which  is  the 
skin  which  covers  one  or  more  of  the  intercostal  spaces  :  the 
eruption,  as  occurring  in  this  situation,  is  so  well  known  that 
it  would  be  waste  of  time  to  describe  it.  In  young  subjects 
zoster  is  commonly  painless,  at  least  the  sensations  are  those  of 


86  COMPLICATIONS  OF  ^"CURALGIA. 

heat,  pricking,  and  irritation,  rather  than  of  acute  pain  ;  but 
from  puberty  onward  there  is  an  increasing  tendency",  espe- 
cially in  those  otherwise  predisposed  to  neuralgia,  for  zoster  to 
be  preceded,  accompanied,  or  followed  by  neuralgia  of  the  in- 
tercostal nerves  corresponding  to  the  distribution  of  the  erup- 
tion. Most  commonly,  the  eruptive  period  is,  in  my  exjperi- 
ence,  nearly  or  quite  free  fi'om  neuralgia,  but  it  often  recurs, 
or  breaks  out  for  the  first  time,  when  the  vesicles  are  drying 
up,  but  more  especially  if,  as  is  sometimes  the  case,  especially 
in  elderly  people,  the  scabs  fall  off  and  leave  superficial  ulcers. 
Neuralgia  may  last,  after  herpes  zoster,  for  any  time  from  a  few 
days  to  many  weeks,  and  I  have  known  it  so  agonizingly  severe 
and  so  persistent  as  actually  to  kill  an  aged  woman  from  sheer 
exhaustion.  In  spite  of  sundry  objections  that  have  been 
raised  to  the  theory  of  the  nervoiis  origin  of  zoster,  it  ai^pears 
to  me  that  the  evidence  in  favor  of  it  is  overwhelming,  more 
especially  now  that  it  is  proved  that  the  disease,  with  all  the 
same  characteristics  presented  by  it  when  seen  on  the  chest  or 
abdomen,  may  occur  on  the  face  (following  the  branches  of  the 
trigeminus),  or  on  the  forearm  (folloT\Tng  the  course  of  nerves 
from  the  brachial  plexus).  Two  of  the  severest  cases  of  neu- 
ralgia attending  herpes  that  I  have  ever  seen  were  in  private 
patients  (whose  family  historj^  tmfortunately,  I  had  no  means 
of  ascertaining)  who  were  affected,  respectively,  in  the  facial 
and  in  the  brachial  nerve-territories. 

A  far  more  formidable  occasional  complication  of  neuralgia 
is  inflammation  affecting  the  eye.  Mr.  Jonathan  Hutchinson 
records  several  cases  m  which  neuralgic  herpes  zoster  of  the 
face  was  attended  with  iritis,  with  serious  or  even  irremediable 
damage  to  the  organ.  For  my  own  part,  i  have  witnessed 
several  instances  in  which _neuralgia  of  the  first  and  second 
divisions  of  the  fifth  has  been  attended  with  skin-inflamma- 
tion, but  only  in  one  of  these  (just  alluded  to)  did  the  inflam- 
mation present  the  characteristic  appearances  of  herpes :_  in  all 
the  rest  it  far  more  closely  resembled  erysipelas.  The  skiu  was 
excessively  reddened  in  an  almost  or  quite  continuous  patch 
over  the  whole  territory  throu.o'h  which  ran  the  painful  nerves ; 
by  no  means  only  linearly  in  the  course  cf  the  nerves,  tliough 
accurately  limited  to  the  district  of  the  first  or  first  and  second 
divisions  of  the  fifth.  In  the  fir?t  case  I  saw  (a  woman,  aged 
thirty-two),  nothing  could  be  m^.e  startling  than  the  rapidity 
with"^ which  an  nregular  patch  of  the  skin,  including  half  of 
one  cheek,  the  side  of  the  nose,  and  a  large  part  of  the  fore- 
head and  scalp  on  the  same  side,  became  convei'ted  into  the 
dense,  fiery-red,  brawny  tissue,  with  minute  vesicles  scattered 
over  its  surface,  which  looks  so  characteristic  of  erysipelas  ; 
this  commenced  immediately  on  the  subsidence  of  severe  neu- 
ralgic pain.  During  the  erysipelatoid  inflammation,  though 
there  was  no  spontaneous  pain,  the  neuralgia  coiild  be  instantly 


COMPLICATIONS  OF  NEURALGIA.  87 

lighted  up  for  a  moment  by  pressure  on  the  infra- orbital  fora- 
men, on  the  supra-orbital  notch,  or  upon  the  malar  bone,  about 
its  centime.  Since  that  time  I  have  seen  several  cases  of  a 
similar  character ;  two  of  these,  which  were  reported  in  tlie 
Lancet  for  1866,  I  shall  here  reproduce :  [Extensive  inquiries 
convinced  me  that  tlie  tendency  to  erysipelatous  complication 
of  facial  neuralgia  is  exceedingly  common.  Eulenburg  ex- 
pressly confirms  my  original  statement  to  this  effect,  and  ex- 
tends it  to  all  neuralgias.] 

Case  I.— A  woman,  aged  sixty-three,  presented  herself  in 
the  out  patient  room  at  Westminster  Hospital,  suffering  from 
neuralgia  of  ten  days'  standing  (which  for  the  present,  how- 
ever, seemed  to  have  abated  considerably),  but  asking  advice 
chiefly  for  an  erysipelatoid  inflammation  which  had  come  on  a 
day  or  two  before,  and  occupied  the  area  of  the  painful  nerve- 
district.  The  neuralgia  had  affected  the  supra-orbital  nerve, 
running  up  toward  the  vortex,  and  the  auriculo- temporal 
branch  of  the  third  division  of  the  fifth ; 'although  there  was  no 
very  acute  pain  i^resent  at  this  time,  pressure  over  the  supra- 
orbital notch,  or  at  a  point  just  in  front  of  the  ear,  would  at 
once  cause  a  brief  paroxysm  of  pain.  It  was  curious  to  find 
that  there  was  a  thickened  and  tender  spot  over  the  malar  bone 
(and  corresponding  to  tlie  exit  of  some  nerve  filam.ents  from 
the  bone)  Avhich  had  never  been  the  seat  of  spontaneous  neu- 
ralgia, but  pressure  here  sent  a  dart  of  pain  into  the  auriculo- 
temporal and  supra-orbital  nerves.  The  inflammation  was 
markedly  limited  to  the  general  area  of  distribution  of  the 
twigs  of  the  auriculo-temporal  and  of  the  ophthalmic  division ; 
it  was  of  a  continuous  deep-red  color,  and  attended  with  much 
thickening  of  the  skin.  The  conjunctiva  was  intensely  con- 
gested, and  there  were  iachrymation  and  very  marked 
photophobia,  but  there  were  no  signs  of  iritis,  and  no  corneal 
clouding. 

Case  II. — M.  W.,  a  woman,  aged  forty-two,  well-nourished 
and  healthy-looking,  married  and  had  one  child ;  had  never 
iiulfered  any  serious  ailment  except  once,  about  five  years  pre- 
viously. She  then  had  a  decided  attack  of  ' '  erysipelas, "  vei-y 
accurately  limited  to  the  right  half  of  the  face.  Five  montlis 
before  coming  to  me  she  sustained  a  severe  shock  from  being 
thrown  out  of  a  chaise,  without  suffering  any  external  or 
visible  damage.  An  hysterical  tendency,  which  she  had  always 
possessed,  became  moi-e  marked ;  it  revealed  itself  by  palpita- 
tions, occasional  dysphagia,  and  a  disposition  to  weep  cause- 
lessly. The  menses  were  flowing  at  the  time  of  the  accident; 
they  ceased  abruptly  soon  after  (they  had  been  scanty  for  some 
time  previously),  and  did  not  recur  till  four  months  later.  The 
hysteric  disturbance  progressively  increased  during  a  fortnight . 
and  then  the  patient  was  attacked  v/ith  violent  intermittent 
neuralgia,  commencing  in  the  eyeball  and  spreading  over  the 


88  COMPLICATIONS  OF  NEURALGIA. 

district  supplied  by  the  branches  of  the  first  and  second  divi- 
sions of  the  trigeminus.  Tlie  pain  was  accompanied  by  intense 
conjunctival  congestion  and  piiotopliobia  [Dr.  Handheld  Jones 
remarks  that  photophobia,  in  his  experience,  is  only  a  rare 
accompaniment  of  facial  neui-algia.  I  have  latterly  come  to 
the  same  opinion.  Redness  of  the  eye  and  lachrymation  are 
very  common ;  true  ])hotophobia  uncommon.  Notta's  expe- 
rience would  seem  to  have  been  similar].  It  lasted  on  the 
first  day  fourteen  hours,  and  returned  daily  for  the  next 
fifteen  or  sixteen  days.  An  attack  of  erysi^Delas,  strictly 
limited  to  the  district  of  the  painful  nervous  branches,  then 
set  in.  From  that  moment  the  neiu'algic  attacks  became  less 
frequent  and  severe.  A  second  similar  onset  of  erysipelas 
occurred  some  three  or  four  weeks  after  the  first.  Finally,  the 
neuralgia  disappeared  about  four  months  after  its  first  occur- 
rence, and  the  menses  reappeared  in  tolerable  abundance  about 
the  same  time.  About  a  fortnight  before  this  the  patient  had 
discovered  that  her  right  eye  was  dim ;  as  the  photophobia  had 
previously  disabled  her  from  opening  the  eye,  she  could  not  be 
sure  how  long  this  dimness  had  existed.  At  the  time  of  her 
visit  to  me  the  cornea  was  blurred  with  a  large  patch  of  inter- 
stitial lymph,  with  the  remains  of  a  superficial  ulcer  in  the 
centre;  the  iris  was  turbid  and  discoloi-ed,  showing  the  traces 
of  recent  but  past  iritis ;  the  pupil  was  regular  in  form  and 
active  to  light ;  the  conjunctiva  was  sliglitly  congested. 
Ophthalmoscopic  observation  was  attempted  by  a  skilled  ob- 
server, but  could  not  be  satisfactorilj^  carried  out,  from  the 
turbid  state  of  the  media.  The  conjunctiva  was  slightly  con- 
gested. In  place  of  the  lachrymation  that  had  prevailed  during 
the  neuralgic  period,  there  was  a  remarkable  insensibility  of 
the  lachrymal  apparatus,  for  the  i^atient  had  noticed  that  the 
smell  of  onions,  which  would  make  the  other  eye  weep  pro- 
fusely, had  no  influence  on  the  affected  one. 

The  family  history  of  this  patient  is  a  most  remarkable  one. 
All  the  members  of  her  mother's  family,  for  tv/o  generations 
back,  had  died  at  middle  age,  either  from  apoplexy  or  some 
disease  involving  hemiplegia.  This  case  has,  by  a  nhstake,  not 
been  added  to  the  list  of  twentj^-two  private  cases  in  which  the 
family  history  was  carefully  investigated,  that  will  be  found 
in  the  chapter  on  Pathology;  this  arose  from  the  fact  that  the 
patient  was  not  properly  under  my  care,  but  was  sent  to  me  as 
a  medical  curiosity;  the  notes  of  her  case  were  therefore  taken 
in  a  different  book  from  the  others.  The  case  certainly  ought 
to  be  taken  as  a  counterpoise  to  such  a  one  as  No.  XVL  in  the 
list,  which  is  that  of  a  gentleman  who  suffered  from  the  most 
complicated  neurotic  maladies  (asthma,  angina  pectoris,  facial 
neuralgia,  more  than  once  attended  with  erysiyelas),  but  whose 
family  history,  so  far  as  it  was  known,  presented  no  traces  of 
tendency  to  neurotic  disease. 


COMPLICATIONS  OF  NEURALGIA.  89 

To  these  two  cases  of  inflammation,  secondary  to  neuralgia,  I 
shall  add  a  third,  which  is  even  more  interesting,  and  which 
came  under  my  notice  not  long  since. 

Case  III. — H.  T.,  watchmaker's  assistant,  aged  forty-two, 
suffered  for  about  three  weeks  with  very  severe  remittent  ab- 
dominal pain,  entirely  unconnected  with  dyspepsia,  con- 
stipation, or  diarrhoea.  It  was  intermittent  in  character,  but 
observation  soon  showed  that  the  times  at  which  it  came  on 
were  simply  those  at  which  the  stomach  had  gone  longest 
without  food,  especially  the  early  morning,  and  that  nourish- 
ment never  failed  to  relieve  it.  The  suffering  was  great,  and 
the  man  failed  considerably  in  general  health,  notwithstanding 
that  his  appetite  and  digestion  were  unimpaired.  He  had  only 
been  under  my  care  about  ten  days  v\rhen  he  presented  himself 
one  day  at  the  hospital,  and  stated  that  the  pains  in  the  stom- 
ach had  entirely  left  him,  but  that  he  suffered  the  most  fright- 
ful pains  in  and  around  the  right  eye.  I  found  a  well-marked 
conjunctival  congestion  and  lachrymation,  but  there  were  as 
yet  no  tender  points ;  the  neuralgia  was  felt  most  severely  in 
the  globe  of  the  eye  and  in  one  tolerably  straight  tine,  darting 
up  toward  the  vertex  from  the  brow.  The  iris  seemed  clear 
and  free,  and  the  cornea  was  not  cloudy.  I  gave  the  man  a 
subcutaneous  injection  of  one-sixth  grain  acetate  of  morphia, 
for  present  ease,  and  ordered  him  muriate  of  iron  and  small 
doses  of  strychnia  three  times  a  day.  When  he  next  appeared, 
four  days  later,  I  was  alarmed  to  perceive  that  unmistakable 
iritis  had  fully  developed  itself,  the  ins  was  already  turbid  and 
discolored  and  the  pupil  irregular,  from  a  serious  amount  of 
adhesions.  By  this  time  there  were  fully-developed  tender 
points,  supra-orbital  and  parietal ;  besides  this,  pressure  on  the 
globe  caused  paroxysms  of  pain  in  all  the  branches  of  the  oph- 
thalmic division,  but  there  was  not  much  spontaneous  pain. 
I  dropped  atropine  in  the  eye,  applied  blistering  fluid  to  the 
back  of  the  neck,  [the  nape  of  the  neck  is  the  point  most  suit- 
able for  blisternig  which  is  intended  to  affect  the  eye,  and  the 
ophthalmic  division  of  the  flfth,  generally,]  and  desired  the 
man  to  come  to  see  me  at  my  own  house  next  day,  intending 
to  take  him  to  an  ophthalmic  surgeon.  Unfortunately  he  failed 
to  do  this,  and  three  days  later,  when  he  came  to  see  me  at  the 
hospital,  the  cornea  was  studded  with  opacities,  the  pupil  was 
almost  closed  with  effused  lymph,  there  was  violent  ocular 
pain,  and  a  great  and  increasng  sense  of  tension.  I  begged 
him  to  go  without  loss  of  time  to  the  Eye  Hospital,  as  my  own 
ophthalmic  colleague  was  not  at  Wesminister  that  day ;  and  I 
have  never  heard  any  more  of  the  patient. 

Glaucoma  is  a  still  more  serious  disease  of  the  eye,  which  I 
think  there  is  now  sufficient  evidence  to  show  is  sometimes 
entirely,  and  very  often  in  considerable  part,  neuralgic  in  its 
origin.     Since  my  attention  was  directed,  some  six  years  ago, 


90  COMPLICATIONS  OF  NEUEALGIA. 

to  the  frequent  connection  between  the  so-called  rheumatic 
mtis  and  neuralgia,  I  have  taken  much  interest  m  the  subject 
of  acute  eye-affections ;  and  the  occurrence  of  one  or  two  cases 
of  glaucoma  in  personal  friends  of  my  own  has  made  this  in- 
terest even  painfully  strong-.  I  ana  necessarily  without  the 
means  of  personally  observing  glaucoma  on  the  large  scale, 
but  I  have  now  seen  two  cases  m  which,  if  I  possess  any  faculty 
of  clinical  observation  whatever,  the  whole  genesis  of  the  dis- 
ease was  a  neuralgic  disorder  of  the  trigeminus ;  and  it  was  to 
me  a  melancholy  reflection  that  nothing  better  than  iridec- 
tomy in  one  case,  and  excision  of  the  eyeball  in  the  other, 
could  be  done  in  the  present  state  of  ophthalmic  science. 
There  are  now  a  good  many  recorded  instances  of  neuralgic 
glaucoma,  and  Mr.  E.  Brudenell  Carter,  of  St.  George's,  and  the 
South  London  Ophthalmic  Hospital,  recently  assured  me  that 
nervous  aspect  of  some  form  of  glaucoma  presents  itself  the 
strongly  to  his  mind,  though  he  does  not  commit  himself  to 
any  theory.  Two  cases  were  rei^orted  by  Mr.  Hutchinson,  in 
Ophthalmic  Hospital  Reports  IV.  and  V. ;  but  the  most  com- 
plete and  interesting  cases  that  I  have  met  with  are  recorded 
by  Dr.  Wegner  ;*  they  are  two  oiit  of  four  that  occurred  within 
a  very  short  time  in  the  clinic  of  Prof.  Horner  at  Zuvich,  and 
they  form  the  basis  of  sonae  researches  by  Wegner  into  the 
nature  of  the  influence  of  the  trigeminus  upon  ocular  tension, 
which  will  be  referred  to,  along  with  others,  in  the  chapter  on 
Pathology.  The  second  of  these  cases  is  so  important  that  I 
shall  reproduce  it  m  full . 

A.  Hediger,  aged  twenty-four,  a  moderately  strongly-built 
young  woman,  seen  first  in  August,  1860.  From  her  own  and 
her  mother's  account,  it  seemed  she  had  long  suffered  from 
convulsive  attacks  that  did  not  appear  to  have  been  truly  epi- 
leptic. Some  days  previously  her  left  eye  became  very  pain- 
ful, and  the  sight  failed,  without  any  infiamniatory  symptoms. 
On  inspection  the  pupil  was  somewhat  dilated,  the  eye  some- 
what hj'permetropic,  fundus  normal ;  No.  5,  Jager's  type,  was 
read  with  difficulty.  Wegner  could  not  explain  the  condition. 
At  the  end  of  October  the  eye  was  much  worse ;  after  severe 
paroxysms  of  pain.  No-  16  type  was  the  smallest  legible,  the 
field  of  vision  was  decidedly  limited  in  all  directions,  but  es- 
pecially on  the  inner  and  upper  portions.  An  unusually 
long  hysteric  attack  was  now  observed.  The  patient 
was  for  twenty-foui'  hours  in  a  half-sleep,  the  extrem- 
ities, meantime,  were  much  jerked,  the  speech  sometimes 
coherent  and  sometimes  incoherent;  she  cried  out  to  her 
friends,  etc. ,  but  had  no  severe  convulsion-fit  with  spasm  of 
glottis.  She  was  removed  to  the  hospital,  where  she  staj^ed  six 
weeks.     The  hysteria  improved  under  treatment  with  valerien 

*Arcliiv  fur  Opbtlialmologie,  B.  xii,,  Ablli.  1,  1866. 


COMPLICATIONS  OF  NEURALGIA.  91 

and  morphia  (Prof.  G-reisiiiger  had  confirmed  the  opinion  that 
there  was  no  true  lesion  of  tlie  centres),  but  the  neuralgia  of 
the  globe  was  extraordinarily  severe,  both  day  and  night. 
From  January  to  June,  1861,  Wegner  saw  her  occasionally. 
Tlie  visual  power  of  the  left  eye  fluctuated  between  15  and  19 
Jager.  Field  of  vision  very  limited.  Pupil  very  dilated  and 
insensitive,  tlie  globe  painful  to  the  touch,  and  injected.  The 
right  eye  weakly  hypermetropic ;  normal  field  of  vision,  nor- 
mal pupil,  no  pain.  The  scene  suddenly  changed  on  the  29th 
of  June.  She  was  attacked  with  fearful  pain,  and  an  enormous 
mydriasis  with  extreme  amblyoi)ia  of  the  riglit  eye ;  the  fing- 
ers could  hardly  be  counted  when  placed  quite  close.  The  op- 
tic disc  appeared  somewhat  cloudy,  with  very  evident  venous 
pulsation.  The  mydriasis,  amblyopia,  and  neuralgia  lasted 
some  time,  while  simultaneously  the  left  eye  could  only  read 
19-17  type,  but  was  painless.  The  pathology  seemed  quite  ob- 
scure, and  the  surgeon  remained  almost  passive  till  August, 
when  he  performed  paracentesis  on  the  left  eye.  The  patient 
could  distinguish  fingers  at  that  time  at  a  foot's  distance  with 
the  I'ight  eye ;  with  the  left  read  No.  11,  but  suffered  fearful 
pains.  These  diminished  after  the  puncture;  the  eye  could 
read  No.  20  next  day,  and  improved  after  that  to  19 ;  the  pams 
recurred  in  the  next  day,  but  for  the  first  time  ceased  to  dis- 
turb sleep.  Tlie  scene  again  changed  in  the  most  surprising 
manner  on  the  27th  of  August.  The  most  frightful  pain  again 
attacked  the  left  eye.  The  pupil  was  dilated  to  the  maximum 
(far  beyond  what  occurs  in  oculo-motor  paralysis) ;  the  globe 
was  extremely  painful  on  touch,  visual  power  fallen  to  19 
Jager.  On  the  otlier  hand,  the  right  eye  had  a  normal  pupil, 
was  painless,  and  could  read  No.  12.  Parencentesis  of  the  left 
eye  improved  its  vision  and  dmiinished  pain,  but  only  tempor- 
arily, so  that  it  had  to  be  repeated  at  short  intervals.  The  con- 
dition was  so  far  stationary  toward  the  end  of  October  that  tlie 
right  eye  continually  gained  visual  power,  but  the  left  stood 
still  and  fluctuated  from  worse  to  better,  with  the  greater  or 
less  severity  of  the  neuralgic  paroxysms.  Pupils  always  in 
extreme  dilatation.  In  the  end  of  October  and  beginning  of 
November  (the  patient  had  worn  a  large  seton  for  a  month)  re- 
markable changes  occurred ;  the  neuralgia  of  the  left  globe  di- 
minished steadily,  the  j)upil  got  smaller,  the  visual  power  in- 
ci'eased,  the  neuralgia  now  was  only  on  the  lower  lid,  which 
was  slightly  red  and  painful  to  the  touch,  and  had  continual 
spontaneous  pain.  Visual  power  of  right  eye  No.  3,  of  left  eye 
No.  5.  Visual  fleld  intact;  with  full  illumination  by  weak  light 
there  is  a  peripheral  torpor,  but  only  in  a  narrow  zone.  The 
hypersemia  now  extended  more  and  more  over  the  lower  lid 
and  the  upper  part  of  the  cheek ;  this  was  apparent  during  the 
paroxysms,  which  were  very  severe,  and  destroyed  sleep ;  it 
did  not  allow  the  skin  to  be  touched;  the  color  was  deep  (with 


92  COMPLICATIONS  OF  NEURALGIA. 

high  temperature)  and  extended  to  the  angle  of  the  mouth, 
This  phenomenon  lasted  till  the  beginning  of  December,  when 
neuralgia  again  attacked  the  left  globe,  with  strong  mydriasis 
and  diminution  of  visual  power  (15  to  20  Jager),  till  at  last  the 
movements  of  the  hand  could  hardly  be  distinguished,  and 
this  state  of  thmgs  continued  with  fluctuations  up  to  the  end 
of  the  month.  The  seton  had  been  taken  off  just  before  the 
new 'outbreak ;  it  was  put  in  again  on  December  31st.  In  Jan- 
uary the  pains  continued  severe  in  the  eye,  with  only  one  re- 
mission (from  the  17tli  to  the  20th),  when  the  hyperaemia  re- 
curred in  the  cheek.  On  the  26th  the  pupil  was  very  dilated, 
and  fingers  could  not  be  seen  at  half  a  foot's  distance.  Visual 
field  very  limited,  globe  hard.  A  large  upper  iridectomy  was 
made.  After  this  the  pupil  was  contracted,  the  pains  dimin- 
ished, visual  power  10  Jager,  field  seven  inches.  In  the  mid- 
dle of  February  the  hysterical  attacks  recurred  with  great 
force ;  the  patient  was  unconscious  half  the  day ;  she  was  clear 
enough  in  senses  when  awake,  but  complained  of  buzzing  in 
her  head,  as  if  a  cock-chafer  were  inside  it.  From  this  till  the 
middle  of  March,  the  left  eye  did  not  alter,  the  impairment  of 
vision  remained,  with  normal  pupil  and  no  pain  in  the  globe, 
and  the  iridectomy  seemed  at  least  to  have  done  good  in  one 
direction ;  but  on  the  13th  of  March  the  operated  eye  was  again 
attacked  with  pain,  visual  power  fell  to  No.  17,  pupil  became 
dilated,  and  offer  a  few  days  the  swelling,  heat,  and  tenderness 
of  the  cheek  recurred.  During  the  years  1862  and  1863  the 
condition  remained  pretty  much  the  same ;  i.  e. ,  the_  right  eye 
sound,  the  left  painful  (in  spite  of  the  iiidectomy)  with  dilated 
pupil,  concentrically  narrowed  visual  field,  visual  power  fluc- 
tuating between  No.  15  and  mere  finger-counting  without  any 
opthalraoscopic  appearances.  A  number  of  paracentesis  and 
subcutaneous  mjections  of  morphia  (which  last  w^ere  the  more 
mdicated  as  the  supra-orbitalis  was  tender  on  pressure)  ahvays 
brought  relief  m.erely  for  a  feAV  hours.  On  the  19th  of  April, 
1864,  vision  being  complete  in  right  eye,  and  No.  19  in  left, 
Wegner  punctured  the  latter.  On  the  2d  of  May  the  eye  read 
No.  10  slowly,  the  pains  had  gone  and  not  returned,  the  pupil 
became  smaller.  On  the  31st  of  March,  1865,  the_  patient  was 
pronounced  w^ell;  the  eye  was  painless,  tlae  pupil  somewhat 
larger  than  the  other;  the  finest  type  could  be  read  when 
looked  at  very  close. 

3.  The  next  group  of  affections  secondary  to  neuralgia  are 
the  paralysis  of  muscles.  These  are  pretty  common ;  I  find 
them  in  twenty-eight  of  the  hundred  cases  which  have  been 
referred  to.  But  of  tliese  twenty-eight  instances  of  paralytic 
affections  no  less  than  twelve  were  connected  with  neuralgia 
of  the  trigemmus,  and  m  most  of  these  it  was  one  or  more  of 
the  muscles  connected  with  the  eye  that  were  affected.  Sci- 
atica is  nearly  always  attended  with  nmch  weakening  of  vol- 


COMPLICATIONS  OF  NEURALGIA.  93 

untary  power  of  the  muscles  of  the  thigh  and  leg ;  and  in  some 
instances  this  reaches  to  decided  or  even  complete  paralysis. 
In  loolcing  for  this  phenomenon  we  must  he  very  careful  that 
we  do  not  mistake  the  mere  reluctance  to  move  the  limb,  on 
account  of  the  pain  fulness  of  all  movements,  for  true  paraly- 
tic wealaiess  of  nerve  and  muscle.  And  it  is  also  necessary  to 
bear  in  nhnd,  in  prolonged  cases,  the  probability  that  much  of 
the  weakness  may  have  been  caused  by  degeneration  of  the 
muscles  owing  to  forced  inaction.  Still,  there  is  a  cjass  of  sec- 
ondary paralyses  that  are  in  no  v/ay  to  be  confounded  with 
such  effects  as  these :  for  instance,  if  occasionally  happens, 
almost  in  the  very  first  onset  of  severe  sciatic  pain,  that  the  limb 
hangs  absolutely  helpless ;  and  i:i  one  such  case  lately,  being 
struck  with  the  completeness  of  the  loss  of  power,  I  tested  the 
Faradic  irritability  by  directing  a  sharp  current  on  compara- 
tively exposed  portions  of  the  painful  nerve  (e.  gr.,  in  the  pop- 
liteal space,  and  behind  the  head  of  the  fibula),  and  elicited 
only  the  most  feeble  contractions,  entirely  unlike  what  the 
same  current  evoked  in  the  opposite  limb.  I  regret  that  I  have 
as  yet  found  it  impossible  to  carry  out  a  regular  inquiry  as  to 
the  seiisibility  to  the  different  currents  of  motor  nerves  which 
are  centrally  connected  with  neuralgic  sensory  nerves. 

Muscular  viscera  which  are  composed  of  unstriped  fibre,  like 
the  intesthies,  or  of  a  mixture  of  striped  and  unstriped,  like 
the  lieart,  are  probably  very  liable  to  a  secondary  paralytic  in- 
fluence from  certain  special  neuralgise.  It  is  ascertained  that 
the  pain  of  a  certain  degree  of  severity  in  the  branches  of  the 
fifth  may  absolutely  stop  the  heart's  action  for  a  moment— an 
effect  which  is  succeeded,  usually,  by  violent  and  disorderly 
j)ulsations.  I  have  myself  once  known  the  operatioii  of  ' '  piv- 
oting" a  tooth,  which  gave  frightful  pain,  cause  instantaneous 
and  most  alarming  arrest  of  the  heart's  motion,  which  for  a 
minute  or  two  seemed  as  if  it  were  going  to  be  fatal.  But  the 
variety  of  visceral  paralysis  which  is  probably  far  the  most 
frequent  is  secondary  paralysis  of  the  bladder,  from  neuralgia 
in  one  or  other  of  the  pelvic  organs,  or  of  the  external  genita- 
lia ;  and  next  to  this  comes  paralytic  distension  of  the  csecum, 
colon,  or  rectum,  secondary  to  various  abdominal  and  pelvic 
neuralgic  affections.  In  one  instance  of  acute  ovarian  neural- 
gia that  I  saw,  the  paralytic  distention  of  the  colon  was  by  far 
the  most  remarkable  circumstance,  so  enormously  was  it  de- 
veloped ;  and  for  some  days  after  the  neuralgia  had  ceased,  and 
when  the  flatulence  had  nearly  disappeared,  the  intestine  re- 
mained absolutely  torpid. 

4.  Convulsive  actions  of  muscles,  as  every  one  knows,  are 
very  common  complications  of  neuralgia.  In  trigeminal  neu- 
ralgias these  may  be  observed  (according  to  the  division  or  di- 
visions of  the  nerve  that  are  affected)  in  the  proper  muscles  of 
the  eye,  or  in  those  supplied  by  the  fourth  and  sixth  nerves,  or 


94  COMPLICATIONS  OF  NEURALGIA, 

(perhaps  only  when  two  or  three  divisions  of  the  fifth  are  neu- 
ralgic at  once)  by  the  portio  dura.  It  is  curious,  however,  that 
those  formidable  spasmodic  affections  of  the  face  which  belong 
to  the  same  order  as  torticollis  and  writer's  cramp,  are  not  fre- 
quently, if  ever,  directly  associated  with  trigeminal  neuralgia. 
The  only  connection  between  them  seems  to  be  that  these  pecu- 
liar spasmodic  affections  are  only  developed  in  highly- 
neurotic  families,  some  of  whose  members  are  almost  sure 
to  be  found  suffering  from  some  form  of  regular  neuralgia 
In  severe  sciatica  it  has  several  times  happened  to  me  to 
see  convulsive  action  of  the  flexors,  bending  the  leg  spasmod- 
ically upon  the  thigh.  And  in  a  very  large  proportion  of  all 
neuralgias,  wherever  situated,  attentive  observation  of  the 
patient  during  the  paroxysms  will  detect  the  existence  ofJLocal 
twitching  or  local  spasm  of  muscles,  though  these  may  be 
slight  in  degree. 

Among  the  convulsive  affections  ixiust  be  reckoned  convul- 
sive movements  and  tonic  si^asms  of  various  portions  of  the 
alimentary  canal.  Vomiting  is  a  common  example  of  this;  in 
migrame  it  Ls  the  regular  and  necessary  climax  of  attacks 
which  last  with  severity  for  a  certain  time ;  mdeed,  any  severe 
attack  of  neuralgia  involving  the  ophthalmic  division  of  the 
fifth  may  excite  vomitiug.  Convulsive  action  of  the  pharyn- 
geal muscles,  as  a  comiplication  of  pharyngeal  or  laryngeal 
neuralgia,  occasionally  occurs  to  such  an  extent  as  to  render 
deglutition  difficult  or  impossible  for  the  time.  And  I  have  seen 
what  I  do  not  doubt  to  have  been  a  spasmodic  condition  of  the 
rectum  induced  by  peri-uterine  neui'algia.  The  genito-urniary 
organs  are  also  not  unfrequeutly  affected  spasmodically  in  con- 
sequence of  a  neuralgic  affection  either  peri-uterine  or  puden- 
dal. I  have  seen  spasmodic  stricture  of  the  male  urethra  thus 
produced,  and  likewise  vagmal  spasm. 

5.  Impairments  of  sensation,  both  comixion  and  special,  are 
very  frequent  attendants  of  neuralgia.  As  regards  the  special 
sensations,  we  may  first  mention  that  of  touch ;  this  is  almost 
constantly  impaired,  immediately  before,  during,  and  some 
little  time  after  a  neuralgic  paroxysm,  in  the  skin  supplied  by 
the  iDainful  nerves.  I  was  first  led  to  make  tlus  observation  Dy 
my  own  experience ;  the  skin  all  round  the  inner  angle  of  my 
right  eye  is  permanently  less  sensitive  to  distinctive  impressions 
than  that  of  the  opposite  side,  and  this  impairment  is  always 
decidedly  greater,  and  spreads  over  a  larger  surface,  before, 
during,  and  for  some  time  after,  the  attacks  of  pain.  More  ex- 
tended observation  has  convinced  nae  that  a  certain  amoimt  of 
bluntness  of  distinctive  skin-sensation  accompanies  nearly 
every  neuralgia.  As  regards  the  sense  of  taste,  I  have  found 
this  decidedly  perverted,  at  the  time  of  an  attack,  even  in  my 
own  case,  although  the  neuralgia  never  extends  into  the  third 
branch  of  the  nerve.     It  is  interesting  to  notice,  in  connection 


COMPLICATIONS  OP  NEURALGIA.  95 

with  this,  that  the  epithehum  of  my  tongue  has  been  seen,  on 
one  occasion,  to  be  exaggerated  on  the  side  of  the  neuralgic 
affection,  showing  a  prol^abihty  that  there  is  perturbed  func- 
tion, at  any  rate  of  certain  fibres,  of  the  third  division.  But  I 
have  seen  much  more  decided  alteration,  indeed  temporary  en- 
tire abeyance  of  the  power  to  distinguish  between  tbe  tastes  of 
different  substances,  with  the  affected  side  of  the  tongue,  in  a 
case  of  severe  epileptiform  tic  in  which  the  third  division  was 
strongly  affected  with  neuralgia ;  and  Notta  records  a  similar 
instance.  As  regards  vision,  besides  minor  perversions  and 
disturbances,  I  have  observed  more  or  less  complete  amaurosis 
in  several  instances  of  ophthalmic  neuralgia ;  in  one  case  it  was 
absolute,  and  lasted,  with  but  slight  improvement  in  the  inter- 
vals between  the  paroxysms,  for  nearly  a  month,  but  disap- 
peared entirely,  though  somewhat  gradually,  after  the  final 
cessation  of  the  neuralgia.  As  regards  hearing,  I  have  noticed 
serious  impairment  only  in  five  cases,  all  of  them  of  a  severe 
type  of  trigeminal  neuralgia,  involving  all  three  divisions  of 
the  nerve.  Smell,  I  have  never  observed  to  be  more  than 
doubtfully  impaired,  except  in  one  case  {vide  Chapter  III), 
where  it  was  completely  destroyed. 

Common  sensation  was  reported  by  Notta  as  affected  in  only 
three  cases  out  of  a  hundred  and  twenty-eight ;  but  my  own 
experience  has  afforded  a  much  larger  proportion  of  instances 
in  trigeminal  neuralgia.  Indeed,  in  all  situations  neuralgia 
appears  to  me  to  involve  this  effect,  in  the  larger  number  of 
instances,  in  the  early  stages ;  later,  it  is  supplanted  in  part  by 
great  tenderness  on  pressure  in  the  well  known  pomis  doulou- 
reux, and  sometimes  the  tenderness  becomes  diffused  over  a 
considerable  surface.  I  agree  with  Eulenburg  in  thinking  that 
anaesthesia  is  more  frequent  in  sciatica  than  in  other  neuralgias. 

6.  Secretion  is  often  very  notably  affected  in  neuralgia ;  the 
phenomena  are  necessarily  more  easily  observed  in  connection 
with  affections  of  the  trigeminal  than  of  other  nerves.  In  the 
great  majority  of  cases  the  affection  is  in  the  direction  of  in- 
crease; at  least,  the  watery  elements  of  secretion  are  often 
poured  out  in  profusion.  Thus,  profuse  lachrymation  is  exceed- 
ingly common  in  ophthalmic  neuralgia;  in  a  large  number  of 
cases  there  is  also  copious  thin  nasal  flux  on  the  affected  side; 
sometimes,  however,  the  secretion,  though  copious,  is  semi- 
purulent,  or  bloody.  Increased  salivation  has  been  noticed,  by 
a  large  number  of  observers,  in  neuralgia  involving  the  lower 
division  of  the  fifth.  In  a  smaller  number  of  instances,  the 
secondary  effect  on  secretion  is  precisely  opposite;  thus  both 
Notta  and  myself  have  observed  complete  dryness  on  the  nos- 
tril on  the  affected  side  in  ophthalmic  neuralgia. 

I  might  expand  this  chapter  on  the  complications  of  neural- 
gia to  a  very  much  greater  length;  but,  as  regards  the  clinical 
history  of  these  affections,  it  is  perhaps  better  not  to  occupy 


96  PATHOLOGY  A^S'D  ETIOLOGY  OF  ^^:^RALGIA. 

more  time  and  space.  It  will,  however,  be  necessary  to  return 
to  the  consideration  of  the  subject  in  connection  with  Patii- 
ology. 


CHAPTER  m. 

PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA. 

The  pathology  and  the  etiology  of  neLU'algia  cannot  be  coii- 
sidered  apart ;  they  nust  be  discussed  together  at  every  step.  I 
do  not  mean  to  say  that  neuralgia  is  singular  among  diseasso 
in  this  respect;  it  seems  to  me  inerely  a  case  in  which  the  in- 
trinsic defects  of  the  conventional  system  of  separating  the 
"  causes  "  of  disease  from  its  pathology  happen  to  be  moreglai'- 
ing  and  more  easih'  demonstrable  than  usual. 

Neuralgia  possesses  no  ' '  pathology, "  if  by  that  word  we  in- 
tend to  signify  the  knowledge  of  definite  anatomical  changes 
always  associated  with  the  disease,  in  a  manner  that  we  can 
exhibit  or  exactly  describe.  It  also  possesses  no  demonstrable 
causes,  if  we  employ  the  word  ' '  causes ""  in  the  old  metaphysical 
sense.  And  yet  I  am  very  far  from  admitting,  what  seems  to 
be  so  generally  taken  for  granted,  that  we  know  less  about  the 
seat,  the  nature,  and  tlie  conditions  of  neiu'algia  than  of  other 
diseases.  On  the  contrary.  I  believe,  with  all  deference  to  the 
supporters  of  the  ordinary-  opinion,  that  we  know  more  about 
neuralgia,  in  all  these  respects,  than  we  do  about  pneumonia, 
only  our  knowledge  is  not  of  the  superficial  and  obvious 
kind,  but  requires  the  aid  of  reason  and  reflection  to  de- 
velop and  turn  it  to  account.  It  has  long  been  a  matter 
of  surprise  to  me,  that  even  able  writer-s  have  been  con- 
tent to  talk  about  this  disease  (as,  indeed,  they  have  been  con- 
tent to  speak  of  many  nervous  diseases)  with  an  inexplicable 
looseness  of  phraseology.  They  speak  of  its  "  protean'"  forms: 
whereas,  in  my  humble  judgment,  its  fornxs  are  03'  no  means 
specially  numerous.  They  insist  on  the  mysterious  and  unin- 
telligible manner  of  its  outbreaks,  remissions  and  departui*e ; 
but  I  shall  try  to  show  that,  although,  in  the  investigation  of 
neralgir,  we  are  continually  stopped  in  particular  lines  of 
inquiry  by  what  seems  to  be  ultimate  facts,  susceptible  of  no 
further  immediate  solution, the  channels  of  information  open  to 
us  are  so  unusually  numerous  as  to  enable  us  to  accumulate  a 
mass  of  information  which,  upon  further  reflection,  will  be 
found  to  furnish  the  materials  of  a  synthesis  of  the  disease  sin- 
gularly clear  and  effective  for  every  practical  purpose  of  the 
physician.  In  one  important  j)articular  I  especially  hope  to 
convince  the  reader  that  a  large  proportion  of  the  mystification 


PATHOLOGY  AJSTD  ETIOLOGY  OF  NEURALGIA.  97 

as  to  tlie  pathology  of  neuralgia  is  gratuitous,  and  tlie  result 
of  great  carelessness  in  estimating  the  comparative  value  of 
different  facts.  I  hope  to  show  clearly  that,  as  regards  both 
the  seat  of  what  must  be  the  essential  part  of  the  morbid  pro- 
cess, and  the  general  nature  of  the  process  itself,  we  possess 
veiy  definite  information  indeed.  I  expect,  in  short,  to  con- 
vince most  readers  that  the  essential  seat  of  every  true  neural- 
gia is  the  posterior  root  of  the  spinal  nerve  in  which  the  pain 
is  felt,  and  that  the  essential  condition  of  the  tissue  of  that 
nerve-r-oot  is  atrophy,  which  is  usually  non-inflammatory  in 
origin.  This  docti'ine  seems,  at  first  sight,  presumptuous,*  in 
the  confessed  absence  or  extreme  scarcity  of  dissections  which 
even  bear  at  all  upon  the  question.  But  one  source  of  the 
extraordinary  interest  which  the  pathology  of  neuralgia  has 
lofig  possessed  for  me  resides  in  this  very  fact,  that  I  am  con- 
vinced we  can  demonstrate  the  above  apparently  difficult  theo- 
rem by  means  of  pathological  observations  on  the  living  sub- 
ject, taken  in  conjunction  with  physiological  experiments,  and 
with  only  the  aid  of  a  very  few  isolated  facts  of  positive  mor- 
bid anatomy.  I  need  hardly  say  that  I  am  none  the  less  anx- 
ious for  that  f ui'ther  assurance  which  we  shall  one  day,  per- 
haps, obtain  by  means  of  greatly  -improved  processes  for 
microscopic  detection  of  minute  changes  in  nerve-centres ;  but, 
looking  to  the  necessary  rarity  of  opportunities  for  post-mor- 
tem examinations  of  the  nervous  system  in  any  but  tlie  most 
advanced  stages  of  neuralgias,  it  will  hardly  be  disputed  th.".t, 
if  I  am  right  in  my  main  position,  Ave  are  singularly  fortunate 
to  be  so  unusually  independent  of  the  need  for  this  source  of 
information. 

1.  The  first  fact  which  strikes  me  as  of  decided  importance 
is  the  position  of  neuralgia  as  an  hereditary  neurosis ;  and  this 
character  of  the  disease  is  so  pregnant  with  significance,  that 
I  shall  take  some  considerable  pains  to  put  the  fact  beyond 
doubt  in  the  reader's  mind. 

There  are  two  series  of  facts  which  support  the  theory  of  the 
inheritance  of  the  neuralgic  tendency :  (a!  instances  in  which 
the  parent  of  the  sufferer  had  also  been  affected  with  the  dis- 
ease ;  and  (6)  instances  in  which  the  family  history  of  the 
patient  being  ti'aced  out  more  at  large  it  appeared  that,  among 
the  members  of  two  or  more  generations,  while  one,  two,  or 
more  individuals  had  been  actually  neuralgic,  other  members 
had  suffered  from  other  serious  neuroses  (such  as  insanity, 

*  Eulenburg,  to  wliose  excellent  woi-k  ("  Lehrbuch  der  fuiictionel- 
len  Nerven-ki-anklieiLeii,"  Berlin,  1871)  I  shall  liave  frequent  occa- 
sion to  refer,  has  partly  misunderstood  the  drift  and  scope  of  my 
argument,  a  misfortune  which  I  owe  to  the  impossibility  of  giving,  in 
the  "system  of  Medicine,"  more  than  the  briefest  and  most  superfi- 
cial sketch,  both  of  my  ideas  and  of  the  facts  on  which  they  rest. 
7 


98  PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA. 

epilepcy,  paralysis,  chorea,  and  the  tendency  to  uncontrollable 
alcoholic  excesses),  and,  in  man\"  instances,  that  this  neurotic 
disposition  was  complicated  with  a  tendency  to  phthisis. 

{a)  The  question  of  the  direct  transmission  of  neuralgia 
itself  from  the  parent  seems  the  easiest  of  decision,  though  even 
this  cannot  alwaj'S  be  satisfactorily  cleared  up  by  the  hospital 
patients,  among  whom  one  collects  the  largest  part  of  one's 
clinical  materials.  However,  I  have  been  at  the  pains  of 
iiiA^estigate  a  hundred  cases  of  all  kinds  of  neuralgia,  seen  in 
hospital  and  private  practice,  with  the  following  results: 
twenty-four  gave  distinct  evidence  that  one  or  other  parent  had 
suffered  from  some  variety  of  neuralgia;  fifty-eight  gave  a  dis- 
tmctly  negative  answer;  and  eighteen  would  not  undertake  to 
give  any  answer  at  all.  Among  the  twentj^-four  affirmatives 
are  inserted  none  in  which  the  history  of  the  parent's  atfecfion 
did  not  clearly  specify  the  liability  to  localized  pain,  of  inter- 
mitting type,  but  recurring  alwayp  in  the  same  situation  dur- 
mg  the  same  illness.  In  three  of  these  twenty-four  instances, 
the  patient  stated  that  both  parents  had  suffered  from  such 
attacks,  and,  in  one  of  these,  it  appeai'ed  that  the  grandfather 
had  likewise  sufFei'ed, 

(b)  Tlie  question  of  the  tendency  of  a  family,  during  two  or 
more  genei'ations,  to  severe  neuroses  of  more  or  less  varying 
kinds,  including  neuralgia,  is  difficult  to  work  out  perfectly, 
though  in  a  large  number  of  mstances  we  may  get  enough 
information  to  be  very  useful.  I  have  spent  much  time  and 
trouble  in  endeavoring  to  collect  such  information  ;  but  there 
are  two  main  difficulties  in  connection  with  all  such  attempts. 
From  hospital  patients  you  frequently  can  get  no  reliable  in- 
formation whatever  respecting  any  members  of  the  family  far- 
ther back  than  the  immediate  parents ;  and,  even  respecting 
uncles  and  aunts  and  first  cousins,  it  is  often  impossible  to  learn 
any  thing.  And  when  you  get  to  a  higher  class  of  society, 
especially  when  you  approach  the  highest,  although  the  infor- 
mation may  exist,  it  may  be  withheld,  or  you  may  be  pur- 
jjosely  myslified.  One  would  doubt  beforehand,  under  these 
circumstances  of  difficulty,  whether  it  would  be  possible  to 
obtain  affimative  e^ndence  of  the  neurotic  temperament  of  the 
families  of  neuralgic  patients  in  general;  but,  in  ti'uth,  the 
evidence  is  so  overwhelming  in  amount,  that  more  than  enough 
can  be  obtamed  for  our  purpose.  I  shall  give,  first,  the  results 
of  one  special  inquiry  which,  by  the  kindness  of  a  patient,  I 
have  been  able  to  cany  out  with  more  than  usual  complete- 
ness; it  relates  to  the  medical  genealogy  of  a  sufferer  from  sci- 
atica ;  the  account  is  fairly  complete  for  foiu^  generations.  The 
great-gi'andfather  was  a  man  of  splendid  physique  (an  only 
son),  who  lived  very  freely,  but  died  an  old  man.  His  child- 
ren were  three  sons,  one  of  wliom  (though  strictly  temperate) 
was  a  man  of  eccentric  and  r.orr.twhat  violent  temper,  and 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  99 

suffered  from  a  spasmodic  facial  affection.  This  one,  the 
grandfather  of  my  patient,  married  a  lady  who  died  of  plithisis, 
and  among  the  ten  children  she  bore  him,  two  sons  died  of 
phthisis,  two  sons  became  chronically  insane,  one  son  died, 
proloably  of  mesenteric  tubercular  disease  (aged  fifty-six),  two 
sons  are  still  alive  at  very  advanced  ages,  and  have  always 
been  perfectly  healthy  and  strong;  one  daughter  died  in  mid- 
dle age,  it  is  not  certain  from  what  cause ;  one  daughter  lived 
healthily  to  the  age  of  eighty,  and  then  was  attacked  by  facial 
erysipelas,  followed  by  violent  and  intractible  epileptiform  tic, 
which  clung  to  her  for  the  remaining  four  years  of  her  life ; 
and  the  remaining  daughter,  an  occasional  sufferer  from 
migraine,  died  at  the  age  of  sixty-seven,  almost  accidentally, 
from  exhausting  summer  diarrhoea.  The  fourth  generation,  in 
this  branch  of  the  family,  consisted  of  thirty-one  individuals ; 
of  whom  seven  have  died  of  phthisis,  or  scrofulous  disease;  one 
from  accidental  violence,  one  from  rheumatic  fever,  one  from 
scarlet  fever ;  and  among  the  surviving  twenty-two  one  has 
been  insane,  but  recovered ;  two  are  decided  neuralgics ;  one  is 
occasionally  migraineuse,  and  once  had  a  smart  attack  of  facial 
erysipelas,  corneitis,  and  iritis,  as  the  climax  to  a  severe  neu- 
ralgic attack ;  one  has  been  a  sufferer  from  chorea ;  one  has 
become  phthisical;  one  developed  strumous  disease,  but  has 
fairly  recovered  from  it.  The  remaining  fifteen  enjoy  good 
health,  but  are  distinguished,  almost  without  exception,  by  a 
markedly  neurotic  temperament,  indicated  by  an  anxious  ten- 
dency of  mind,  quickness  of  perception,  aesthetic  taste,  dispo- 
sition to  alternations  of  impulse  and  procrastination.  Of  the 
young  fifth  generation  growing  ui^,  there  have  been  tv/enty- 
five  children,  of  wfiom  only  one  has  died  (from  fever),  the  rest 
are  apparently  healthy  (most  of  them  specially  so) ;  but,  as  few 
have  yet  reached  the  age  for  the  development  either  of  phthisis 
or  of  neurotic  diseases,  the  future  of  this  generation  can  only 
be  guessed  at.  [It  is  unnecessary  to  trace  the  other  descendants 
of  the  second  generation,  but  I  may  state  that  their  medical 
history,  also,  strongly  supj)orts  the  theory  of  inheritance  of  the 
neurotic  tendency,  and  of  the  influence  of  an  imported  element 
of  phthisis  ua  aggravating  the  latter.]  I  suspect  that,  as 
regards  the  young  children  now  growing  up,  everything  will 
depend  on  the  care  with  which  they  are  fed,  and  the  kind  of 
moral  influences  brought  to  bear  on  them,  two  subjects  which 
will  be  fully  dwelt  on  in  the  chapter  on  Treatment. 

Of  less  perfect  inquiries  on  the  subject  of  neurotic  disposition 
inherited  by  neuralgic  patients,  I  have  made  a  great  number, 
though  I  regret  to  say  that  I  have  not  attempted  the  task  in  the 
whole  number  of  those  from  whom  I  inquired  as  to  direct  in- 
heritance of  neuralgia  from  their  parents.  However,  in  eighty- 
three  cases  this  vv^as  done  with  all  possible  care,  and  any  defi- 
ciency of  completeness  in  the  results  is  not  my  fault.      I  shall 


100  PATHOLOGY  AND  ETIOLOGY  OF  NEURALGL4. 

take  first  those  tliat  were  j)rivate  patients,  twenty-two  in  num- 
ber, resioectiiig  whom,  I  may  say,  that  the  evidence  is  of  the 
best,  as  far  as  it  goes,  since  I  was  better  able  to  discrimmate  as 
to  the  worth  of  statements,  than  in  dealmg  with  hospital 
patients,  and  have  rejected  eveiy  case  in  which  the  uiformant 
did  not  seem,  intelligent  enough,  or  otherwise  to  have  the 
means,  to  give  a  thoroughly  reliable  account. 

I.  Neuralgia  ceiwico-brachialis ;  in  a  lady,  aged  seventy- 
one.      Mother    suffered    suffered    frora  •  e^Dileptif orm 
facial  tic ;  uncle  was  paralyzed ;   patient  herseli  eccen- 
tric to  the  verge  of  insanity. 
n.  Bilateral  sciatica  of  great  severitj" ;    in  a  gentleman, 
aged  seventy-tln-ee.      Gout,  paralysis,   and  neuralgia, 
have  been  frequent  in  the  family. 
in.  Cardiac  neui'algia ;  in  a  man,  aged  twenty-four.     Fa- 
ther epileptic  and  a  drinker ;  grandfather  died  of  sof- 
tenmg  of  the  brain,  aged  thu'ty-eight. 
rV.   "  Cerebral"  neui'algia ;  in  a  single  lady,  aged  thuiy- 
eight.     Mother  has  been  insane ;  first  cousin  epileptic. 
V.  Lumbo-abdominal  neuralgia;    in  a  gentleman,  aged 
fifty-two.     Father  a  di-uiker ;  mother  insane ;    mater- 
nal grandfather  phthisical. 
VI.  Severe  neurotic  angma  pectoris ;  in  a  gentleman,  aged 
fifty.     Almost  every  one  of  the  graver  neuroses  among 
patient's  near  relations. 
Vil.  Migraine  and  cervico-occipital  ueuralgia;   in  a  young 
lady,   aged  twenty-five.       Immediate  causes,   brain- 
work,    and  influence   of  cold  weather.     Father  and 
brother  both  epileptic ;  father's  family  much  affected 
with  neurotic  diseases. 
Vm.  Sciatica ;  highly-nervous  temperament.      Father  died 
insane  from  drink ;  and  probably  other  raembers  of 
the  family  also  nearly  or  quite  insane. 
IX.  Auriculo-temporal  neuralgia ;  in  a  mai'ried  lady,  aged 
twenty-eight.      Father's  family  markedly  phtliisical 
and  neuralgic. 
X.     ntercostal  neuralgia;    in  a  girl    (phthisical),    aged 
twenty-four.     Mother  and    two  uncles  phthisical; 
maternal  grandfather  epileptic  and  a  drinker. 
XI.  Facial  neuralgia  (third  branch  trigeminal) ;  in  a  gen- 
tleman,  aged  fiftj'-four,    a  gi'eat  whiskey-drinker. 
Drinking  hereditary  for  three  generations;   father 
died  insane ;  grandfather  epileptic ;  sister  phthisical ; 
two  brothers  very  "  eccentric." 
XII.  Migraine,  severe ;  in  a  lady,  aged  thirty-three.     Grief 
was  the  immediate  cause.     Motlier  hemiplegic  at 
forty-second   year;   fh-st  cousin  insane;  two  aunts 
(maternal)  epileptic. 
Xin.  Extremely  severe  sciatica  sjnf.  ^e.'-'vico-braclaial  neural- 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  101 

gia  of  tlie  left  side,  with  singular  infiaminatory"  con- 
sequences;   in  a  lady,    aged  fifty -two.      A  family 
history  remarkably  free  from  neurotic  diseases  and 
from  phthisis.     The  neuralgia  was  probably  caused 
partly  by  excessive  ptyalism,  pai-tly  by  over  brain- 
work. 
XIV.  Migraine ;  in  a  young  lady,  aged  sixteen ;  very  profuse 
menstruation,  which  had  lasted  for  two  years.  Fam- 
ily history  very  free  both  from  phthisis  and  neu- 
roses. 
XV.  Frontal  and  nasal  neuralgia;    in  a  man.     Repeated 
attacks  of  localized  facial  erysipelas ;  drinking-habits 
for  some  years ;  fatal  acute  insanity  in  middle  age. 
Father  insane,  committed  suicide ;  mother  subject  of 
violent  epileptiform  tic. 
XVI.  Angina  pectoris  (neurotic) ;  spasmodic  asthma,  twenty 
years;  facial  neuralgia  and  erysipel&s;  in  a  gentle- 
man,  aged  fifty.     Family  medical   history  scanty 
and  imperfect;  but,  as  far  as  it  goes,  entirely  with- 
out evidence  of  either  phthisis  or  neuroses. 
XVn.  Neuralgia  of  testis,  immediately  caused  by  local  irrita- 
tion.    Father  died  of  phthisis ;  paternal  uncle  epi- 
leptic and  insane. 
XVIII.  Ovarian  neuralgia;  in  a  girl,  aged  twenty-six,  liable 
to  occasional  migraine.     Mother  has  suffered  sciat- 
ica; brother  died  of  phthisis. 
XIX.  Gastralgia;    in  a    man,    aged   twen ty -seven ;    highly 
intellectual  and  nervous.     Famity  history  very  free 
from  neuroses;  but  some  evidence  of  phthisis,  in 
two  previous  generations,  on  mother's  side. 
XX.  Sciataca;  in  a  lady,  aged  sixty;  second  attack.     An- 
cestors, on  both  sides,  for  some  generations,  clever, 
and  in  several  instances  decidedly  eccentric,  if  not 
insane;  much  neuralgia  in  the  family. 
XXI.  Migraine;  in  a   young  lady,    aged   seventeen;   men- 
strual difficulties.     No  neurotic  nor  phthisical  family 
history. 
XXII.  Sciatica ;  in  a  married  lady,  aged  twenty-seven ;  first 
pregnancy;    had   rheumatic   fever  and  subsequent 
chorea    in    childhood.      Paternal    uncle    epileptic; 
mother  had  rheumatic  fever  and  cardiac  disease;  pa- 
ternal grandfatiier  suffered  from  sciatica  late  in  life. 
No  one,  I  think,  can  look  down  the  above  list  and  fail  to  be 
struck  with  the  great  preponderance  of  cases  in  which  the  gen- 
eral neurotic  temperament  plainly  existed  in  the  patients'  fam- 
ilies; and  let  me  add  that,   in  not  a  few  of  these  cases,  the 
neuralgia  in  the  individual  under  observation  might  have  been 
easily  set  down  as  dependent  merely  upon  peripheral  irritation, 
which,  indeed,  plainly  did  act  as  a  concurrent  cause. 


102  PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA. 

Fortunately,  however,  I  am  not  dependent  upon  nay  own 
evidence  alone,  for  the  proofs  of  the  proposition  that  neuralgia 
is  eminently  a  development  of  hereditary  neuroses.  The  great 
French  alienists,  Morel  and  Moreau  of  Tours,  some  years  ago 
laid  the  foundations  of  the  doctrine  of  hereditary  neurosis. 
They  enforced  this  chiefly  with  reference  to  the  manner  in 
which  insanity  is  transmitted  through  a  chain  of  variously- 
neurotic  members  of  a  family  stock;  and  Moreau  laid  sjiecial 
stress  on  the  deeply  interesting  connection  of  the  phthisical 
with  the  neurotic  tendency.  Since  then  various  obsei'vers  have 
insisted  on  the  same  thing.  Of  late,  Dr.  Maudsley  has  worked 
out  this  siibject  with  great  ability,  in  his  work  ' '  On  the  Phys- 
iology and  Pathology  of  Mind,"  and  in  his  recent  "  Gulstonian 
Lectures ;"  and  Dr.  Blandf ord  dwells  on  it  with  emphasis  in 
his  intei'osting  "  Lectures  on  Insanity."  [Dr.  Blandf  ord  does 
not,  liowever,  admit  that  the  phthisical  diathesis  has  any  such 
close  and  causal  relation  with  neuroses  as  has  been  imagined 
by  some  recent  pathologists ;  and,  on  the  other  hand,  he  pohits 
out  that  phthisis  in  neurotic  subjects,  e.  g.,  the  insane,  must, 
in  a  large  measure,  be  considered  the  ]pi'oduct  of  the  acciden- 
tally unhealthy  circunxstances  in  which  they  pass  their 
lives.  Lithe  latter  opinion  I  entirely  agree.]  La  deed,  it  may  be 
taken  as  a  recognized  fact,  among  the  more  advanced  students 
of  nervous  diseases,  that  hereditary  neurosis  is  an  imi^ortant 
antecedent  of  neuralgia,  in  at  least  a  very  large  number  of 
instances.  I  shall  conclude  this  part  of  the  argument  by  stat- 
ing the  general  results  of  my  inquiries  respectmg  sixty-ono 
hospital  ijatients.  Of  these  cases,  twenty-two  were  migraine, 
or  some  other  affection  of  the  ophthalmic  division  of  the  fifth 
nerve;  seven  were  sciatica;  two  were  epileptiform  facial  tic; 
ten  were  neuralgias  affecting  chiefly  the  second  and  third  divi- 
sions of  the  fifth  nerve ;  three  were  intercostal  neuralgias  pure ; 
one  was  intercostal  neuralgia  plus  anginoid  ]3ain ;  seven  were  in- 
tercostal neuralgias  with  zoster ;  three  were  iDrachial  neuralgias ; 
and  five  were  abdominal  neuralgias  (hepatic,  gastric,  mesentei'ic, 
etc.)  Of  eighty- three  hos23ital  and  private  patients  [It  must  be 
understood  that  the  resjDective  numbers  do  not  indicate  with 
any  accuracy  the  relative  frequencj'^  of  the  different  neuralgias 
as  seen  in  my  practice.  (Sciatica,  e.  g.,  was  proportionally 
more  frequent.)  They  represent  biit  a  small  pai't  of  the  neu- 
ralgic patients  whom  I  have  seen  during  fourteen  years  of  dis- 
pensary, hospital,  and  private  practice,  and  they  were  selected 
for  inquiry  merely  because  I  happened  to  be  able  to  give  the 
time  for  the  necessary  questions.  Every  one  who  knows  out- 
patient practice  will  uiKlerstand  how  seldom  this  happened.] 
I  obtained  evidence  of  the  presence,  among  blood-relations,  of 
the  following  diseases:  Epilepsy,  fourteen  cases  (eight  were 
examples  of  migraine);  hemiplegia  or  paraplegia,  nine  cases; 
insanity,  twelve  cases ;  drunken  habits,  fourteen  cases ;  ' '  con- 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  103 

aumption,"  eighteen  cases;  "  St.  Vitus's  dance,"  four  cases.  I 
ani  well  aware  that  these  figures  must  be  taken  with  caution, 
and  that  considerable  doubt  must  rest  on  the  accuracy  of  some 
of  these  details,  more  especially  with  regard  to  "  epileiosy, "  as 
it  was  impossible,  with  the  greatest  care,  to  be  sui'e  that  this 
was  not  given,  by  mistake,  for  hysteria  m  some  cases ;  and  the 
same  may  apply  to  the  statement  that  relations  had  suffered 
from  "consum\)tion."  The  facts  are  given  for  what  they  ai'e 
worth,  and  with  the  express  reservation  that  their  total  reli- 
ability is  far  less  than  that  of  the  accounts  obtained  resi)ecting 
private  patients  belonging  to  the  rnore  educated  classes.  But, 
in  one  respect,  viz .,  as  regards  di'unken  habits,  it  is  possible 
that  a  truer  estimate  is  gained  from  the  statements  of  hospital 
patients  than  from  those  of  private  patients,  who  would  usually 
be  more  prone  to  reticence  on  such  a  topic. 

The  evidence  as  to  ilie  hereditary  character  of  neuralgia  as- 
sumes a  j-et  higher  importance  when  supplemented  by  the  facts 
respecting  the  alternations  of  neuralgia  with  other  neuroses  as- 
the  same  individuals.  Every  practitioner  must  be  aware  how 
freq[uent  is  the  latter  occurrence.  Notlnng  is  more  common, 
for  example,  than  to  see  insanity  developed  as  the  climax  of 
minor  nervous  troubles,  especially  of  neuralgia.  And  there  is 
one  form  of  neuralgia,  the  true  epileptiform  tic,  which  is  inti- 
mately bound  up  with  a  mental  condition  of  the  nature  of  mel- 
ancholia, and  even  with  the  markedly  suicidal  form  of  the  lat- 
ter affection.  I  have  lately  had  under  my  care  a  lady  m  whom 
the  prodromata  of  a  severe  facial  neuralgia  were  mental ;  the 
disturbance  commenced  with  frightful  dreams,  and  there  was 
great  raental  agitation  even  before  the  pain  broke  out ;  this 
disturbance  of  mind,  however,  continued  during  the  whole 
period  of  the  neuralgia,  and  v/as  relieved  simultaneously  with 
the  cessation  of  the  attacks  of  pain.  This  is  contrary  to  what 
hapx>ens  in _some  cases;  thus,  l)r.  Maudsley  quotes  the  case  of 
an  able  divine  who  was  liable  to  alternations  of  neuralgia  and 
insanity,  the  one  affection  disappearing  when  the  other  pre- 
vailed. Dr.  Blandf  ord  has  met  with  several  instances  in  which 
neuralgia  has  been  followed  by  insanity,  the  pain  vanishmg 
dui^ng  the  mental  disturbance,  and  reappearing  as  the  latter 
passed  away.  And  he  remarks  that,  in  the  transition  of  a  neu- 
ralgia (to  mental  affection),  we  may  well  believe  that  the  neu- 
rotic affection  is  merely  changed  frora  one  centre  to  another, 
from  the  centres  of  sensation  to  those  of  mind.  He  says  that 
the  ultimate  prognosis  of  such  cases  is  bad ;  a  point  to  which 
we  shall  have  to  refer  again. 

The  prominent  place  which  quasi-neuralgic  pains  hold  in  the 
earlier  history  of  locomotor  ataxy  is  a  fact  that  cannot  but 
engage  attention.  In  this  volume  we  have  not  treated  these 
pains  as  belonging  to  the  truly  neuralgic  class,  for  the  very 
practical  reason  that  they  are  but  mcidents  in  a  most  import- 


104  PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA. 

ant  organic  disease,  and  that  iu  a  diagnostic  and  prognostic 
point  of  view  it  is  neceesary  to  dv;ell  on  their  connection  with 
that  disease.  Ev.t,  in  considering  the  pathological  relations  of 
neuralgia,  it  -vvould  he  improper  to  omit  the  consideration  of 
the  pains  of  locomotor  ataxy,  which  bear  a  strikmg  semblance 
to  neuralgic  pains.  The  fact  that  they  are  an  almost  if  not 
quite  constant  feature  of  a  disease  which  is  from  first  to  last  an 
atrophic  affection  (mainly  of  the  posterior  columns  of  the  cord), 
in  which  the  posterior  roots  of  the  nerves  are  almost  always 
deeply  involved,  has  a  bearing  on  our  present  inquiry  too 
obvious  to  need  further  remark. 

Eqiially  important  to  our  investigation  is  the  fact  that  pains, 
closely  resembling  neuralgia,  are  not  very  uncommonly  a  part 
of  the  phenomena  of  commencing,  and  more  frequently  of 
receding,  spinal  paralysis.  I  ha,ve  the  notes  of  three  cases  of 
partial  recovery  from  paraplegia,  in  all  of  which  the  patients 
remained  for  years,  in  one  case  for  nearly  tvy^enty  years  (end- 
ing with  death),  the  victims  to  a  singularly  intractable  neural- 
gia of  both  lower  extremities.  In  the  worst  of  the  cases  the 
patient  was  the  victim  of  excessive  and  continuous  labor  at  lit- 
erary work  of  a  kind  which  hardly  exercised  the  mental  pow- 
ers, but  was  extremely  exhausting  to  the  general  power  of  the 
nervous  system;  he  broke  down  at  about  the  age  of  fifty,  but 
dragged  on  a  painful  existence  for  the  long  period  above  men- 
tioned. 

We  are  also  certainly  entitled  to  adduce  the  example  of  the 
so-called  neuralgic  form  of  chronic  alcoholism  as  an  instance 
of  the  close  relationship  of  neuralgia  to  other  central  neuroses. 
I  refer  to  those  cases,  more  common  perhaps  than  is  generally 
admitted,  in  which  pains  in  the  extremities,  often  quite  resem- 
bling neuralgia  in  their  intermittence,  are  either  superadded 
to  or  take  the  place  of  the  muscular  tremors  and  general  rest- 
lessness that  are  more  popularly  considered  as  the  essential 
nervotis  phenomena  of  chronic  alcoholic  poisoning.  That  the 
pains  are  usually  bilateral,  and  more  diffuse  in  their  character 
than  those  of  ordinaiy  neuralgia,  is  a  fact  wliich  it  is  not  diffi- 
cult to  explain  by  the  modus  opercmcU  of  the  cause  \  but  we 
shall  have  more  to  say  on  the  general  relations  of  alcoholic 
excess  to  neuralgia  presently.  The  pains  themselves  will  be 
fully  described  in  the  second  part  of  this  book,  which  treats  of 
the  affectidiis  that  simulate  neuralgia;  here  we  need  only 
remark  that  it  is  not  uncommon  for  them,  to  occur  inter- 
changeably with  true  neuralgia  in  the  same  person. 

The  occasional  mterchangeability  of  migraine  with  epilepsy 
is  a  well-knoAvn  fact ;  eveiy  practitioner  who  has  seen  much 
of  the  latter  disease  will  have  seen  some  cases  in  which  the 
patient  had  been  liable,  at  some  xioint  of  his  medical  history, 
to  "sick-headaches  "  of  a  truly  neuralgic  kind;  although  it  is 
quite  true,  as  Dr.  Reynolds  points  out,  that  the  kind  of  senso- 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  lOS 

rial  disorder  specially  premonitory  of  the  attacks  consists  rather 
in  indefinable  distressing  sensations,  than  in  actual  pain.  The 
aological  connection  between  migraine  and  epilepsy  is,  as 
I  have  already  stated,  apparently  very  close.  Such  instances 
as  one  mentioned  by  Eulenburg  are  rightly  explained  by  him; 
it  is  the  case  of  a  girl  wHo  suffered  at  an  unusually  early  age 
(nine)  from  migraine;  her  inother  had  been  a  migraineuse, 
and  her  sister  was  epileptic ;  the  sti'ong  neurotic  family  tend- 
ency is  believed  by  Eulenburg  to  account  for  the  appearance  of 
migraine  at  such  a  period  of  life. 

This  seems  the  fitting  place  to  introduce  some  special  remarks 
on  migraine  in  its  relations  to  other  neuralgias  of  the  head, 
because  Eulenburg  has  mentioned  and  combated  my  view, 
according  to  which  migraine  is  a  mere  variety  of  neuralgia  of 
the  ophthalmic  division  of  the  fifth  nerve.  I  call  it  my  view, 
because,  though  several  other  authors  had  previously  expressed 
it,  I  was  first  lead  to  entertain  it  by  observations  made  before 
I  had  studied  their  works,  and  especially  by  the  imiiressive 
teaching  of  my  own  case,  as  to  which  more  will  be  presently 
said.  Eulenburg,  though  he  fully  allows  that  migraine  is  a 
neuralgia,  urges  a  series  of  objections  to  the  identification  of 
migraine  with  ophthalmic  neuralgias ;  of  which  objections  one, 
based  on  the  doctrine  of  Da  Bois  Reymond  as  to  the  action  of 
the  sympathetic  in  migraine,  must  be  reserved  for  consideration 
when  we  discuss  the  general  pathology  of  the  vaso-motor  com- 
plications of  neuralgia.  The  other  grounds  of  distinction  that 
he  urges  are  the  following :  In  the  fii'st  place,  he  remarks  that 
the  site  of  the  pain  is  by  far  less  distinctly  referred  to  definite 
foci  on  the  outside  of  the  skull  than  in  trigeminal  neuralgia ; 
the  patient's  sensations  very  usually  lead  him  to  declare  that 
the  pain  is  in  the  brain  itself.  Secondly,  he  says  that  the 
points  douloureux  (in  Valleix's  sense)  are  almost  constantly 
absent  in  true  migraine.  Thirdly,  he  specifies  the  character  of 
the  pain  in  migraine — dull,  boring,  straining,  etc.— as  differ- 
ing from  that  of  trigeminal  neui'algia,  which  is  ordinarily 
much  more  acute  and  darting.  Fourthly,  he  notes  the  long 
duration  of  individual  attacks  of  migraine,  and  the  long  inter- 
vals (very  commonly  three  or  four  weeks)  between  them. 
Fifthly,  he  dwells  on  the  frequent  prodromata  of  migraine 
referable  to  the  organs  of  sense  (flashes  before  the  eyes,  noises 
in  the  ears),  or  to  the  stomach  (nausea),  or  more  generally  to 
the  reflex  functions  of  the  medulla  oblongata  (e.  (/.,  convulsive 
rigors,  excessive  yawning,  etc.) 

Now,  I  should  have  aiothing  to  say  against  the  accuracy  of 
this  description,  did  it  apply  merely  to  the  distinctions  between 
highly-typical  cases  of  .the  ' '  sick-headache ''  of  the  period  of 
bodily  development,  and  highly-typical  cases  of  the  ophthal- 
mic neuralgias  which  are  commonest  in  the  middle  and  later 
periods  of  life;  nor  indeed  should  I  greatly  care  if  it  were 


106  PATHOLOGY-  AND  ETIOLOGY  OF  NEURALGL4.. 

finally  decided  that  migraine  and  clavus  should  be  separated 
from  the  true  trigeminal  neuralgiae,  provided  the  following- 
points  were  well  impressed  on  the  minds  of  joractitiouers.  In 
the  first  place,  I  must  insist  that  in  my  own  experience  the 
great  majority  of  undoubtedly  neuralgic  headaches,  w^hich  sub- 
ordinate stomach  disturbance,  are  far  less  sharply  separated 
than  the  above  description  would  allow  from  the  unmistakable 
trigeramal  neuralgias ;  it  is  only  a  mmority  of  cases  that  wear 
this  extreme  type,  and  a  far  larger  number  shade  imperceptibly 
away  toward  the  type  of  oi)hthalmic  neuralgia  pure  and  simple. 
And  so,  again,  of  the  so-called  clavus  there  is  every  variety, 
from  a  form  bordering  closely  on  the  migraine  type  to  another, 
differing  in  nothing  from  an  unusually  severe  ocular  and 
frontal  neuralgia  of  the  fifth,  except  in  the  presence  of  a  tre- 
mendously painful  parietal  focus.  But  the  fact  on  which  I 
would  most  particularly  insist  is  one  that  was  first  taught  me 
by  my  personal  experience,  viz. ,  that  migraine  is,  with  extra- 
ordinary frequency,  the  primary  or  youthful  type  of  a  nem-al- 
gia  which,  in  later  years,  entirely  loses  the  special  characters 
of  scik-headache,  and  assumes  those  of  ordinary  frontal  neu- 
ralgia, with  or  without  complications.  In  my  own  case,  the 
"sick-headache"  character  of  the  affection  was  strongly 
marked  during  the  first  two  or  three  years,  after  which  time  it 
gradually  but  steadily  lost  all  tendencies  to  stomach  compli- 
cations, and,  what  is  more,  the  type  of  the  recurrence  became 
entirely  changed.  Yet  it  is  quite  impossible  to  believe  that  the 
malady  is  now  a  different  one,  in  any  essential  pathological 
point,  from  what  it  was  at  first ;  if  any  disproof  of  this  were 
needed,  it  might  be  remarked  that  the  singular  series  of  sec- 
ondary trophic  changes  which  have  complicated  my  case  have 
been  impartially  distributed  between  the  respective  periods 
when  the  affection  was  frankly  migraineuse,  when  it  was 
mixed,  and  wdien  it  was  simply  ophthalmic  neuralgia  (as  it  is 
at  present  ;)  indeed,  some  of  the  most  decided  of  these  trophic 
complications  (orbital  periostitis,  corneal  ulceration,  fibrous 
obstruction  of  the  nasal  duct)  occurred  withia  the  period  in 
which  every  attack  of  pain,  unless  I  succeeded  in  getting  to 
sleep  very  shortly,  ended  in  violent  vomiting.  The  experience 
thus  gained  has  made  me  very  attentive  to  the  past  history  of 
those  who,  in  later  life,  complain  of  fi'ontal  neuralgia  without 
stomach  complication,  and  it  is  surprising  to  find  in  how  many 
cases  patients,  who  at  first  declare  that  they  never  had  neu- 
ralgia before,  on  refiection  will  recall  the  fact  that  they  were 
often  "  bilious  "  in  their^youth ;  which  "  biliousness  "  turns  out 
to  have  been  regularly  preceded  by  one-sided  headache,  and  to 
have  been  severe  in  proportion  to  the  severity  and  duration  of 
that  previous  headache. 

I  ask  the  reader  to  dwell  with  fixed  attention  on  this  fact  of 
the  exclusiveness,  or  almost  exclusiveness,  with  which  the  neu- 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  107 

ralgias  of  tlie  anterior  jDart  of  the  head  ai'e  represented  during 
the  period  of  bodily  development,  and  especially  La  the  years 
just  succeeding  puberty,  by  migraine  or  by  clavus.  When  this 
fact  has  thoroughly  entered  the  mind,  we  can  hardly  help 
joining  with  it  that  other  and  most  important  fact  already 
noticed,  of  the  close  connection  between  the  predisposition  to 
migraine  and  the  predisposition  to  epilepsy,  and  reflecting 
further  on  the  strong  tendency  which  epilepsy  likewise  shows 
to  infest  the  earlier  years  of  sexual  life.  In  view  of  these  things, 
it  is  difficult  to  avoid  the  inference  that  both  the  epileptic  and 
the  neuralgic  affections  of  this  critical  period  of  life  are  the 
expression  of  a  morbid  condition  of  the  medulla  oblongata,  in 
which  the  sensory  root  of  the  trigemmus  has  its  origin  ;  and 
further,  that  this  morbid  condition  (tending  to  explosive  and 
atactic  manifestations  of  nerve-force)  must  have  its  basis  in 
defective  nutrition.  For,  be  it  remembered,  the  epoch  of  sexual 
development  is  one  in  which  an  enormous  addition  is  being 
made  to  the  expenditure  of  vital  energy ;  besides  the  continuous 
processes  of  the  growth  of  the  tissues  and  organs  generally,  the 
sexual  apparatus,  with  its  nervous  supply,  is  making  by  its 
development  heavy;  demands  upon  the  nutritive  powers  of  the 
organism  ;  and,  it  is  scarcely  possible  but  that  portions  of  the 
nervous  centres,  not  directly  connected  with  it,  should  propor- 
tionally sufL'er  in  their  nutrition,  probably  through  defective 
blood-supply.  Wlien  we  add  to  this  the  abnormal  strain  that 
is  being  put  on  the  brain,  in  many  cases,  by  a  forcing  plan  of 
mental  education,  we  shall  perceive  a  source  not  merely  of 
exhaustive  expenditure  of  nervous  power,  but  of  secondary 
irritation  of  centres  like  the  medulla  oblongata,  that  are  prob- 
ably already  somewhat  lowered  in  power  of  vital  resistance, 
ajicl  proportionably  irritable.  Let  us  suppose,  then,  that  to  all 
these  unfavorable  conditions  there  was  added  the  circumstance 
that  the  structure  of  the  medulla  oblongata,  or  of  parts  of  it, 
was  congenitally  weak  and  imperfect  ;  then  surely  it  would  be 
scarcely  possible  for  these  loci  minimse  resistentire  to  escape 
being  thrown  into  that  state  of  weak  and  disorderly  commo- 
tion which  eminently  favors  pain  in  the  sensory,  and  convul- 
sion in  the  rdotor  apparatus. 

2.  We  have  so  far  been  mainly  considering  the  relations  to 
the  production  of  neuralgia  of  certain  conditions  of  the  cen- 
tral nervous  system  which  indisputably  are  inherent  from 
birth.  Let  us  now  pass  quite  to  the  other  extreme,  and  con- 
sider a  class  of  momenta  wliich  take  a  decided  part  in  produc- 
ing many  neuralgise,  but  which  are  altogether  accidental  and 
factitious,  and  cannot  be  included  among  the  necessary  hostile 
conditions  of  life.  To  ptish  the  contrast  to  the  utmost,  let  us 
inquire  first,  what  amount  of  influence  in  the  production  of 
neuralgia  can  ^be  given  by  such  a  purely  "  functional"  influ- 
ence as  educational  misdirection  of  intellect  and  emotion  ? 


108  PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA. 

It  is  somewliat  strange,  though,  every  one  accepts  as  a  mere 
truism  the  maxim  that  sudden  emotional  shock  may  produce 
almost  any  degree  or  variety  of  nervous  disorder,  the  slower 
but  far  surer  influence  of  long-continued  mental  habit  is  often 
practically  ignored.  It  cannot,  mdeed,  be  left  out  of  sight  as 
a  cause  of  disorders  of  the  mind  itself,  nor  are  there  many  who 
would  deny  that  such  diseases  as  cerebral  softening  are,  in  a 
considerable  number  of  cases,  the  premature  ending  to  a  life 
that  has  been  broken  down  by  harrassing  work  and  anxiety. 
But  what  is  far  less  appreciated  is  the  tendency  of  certain 
unfortunate  mental  surroundings  and  modes  of  mental  life  to 
produce  a  generally  neurotic  condition,  which  may  express 
itself  in  a  variety  of  functional  disorders,  among  which  not 
the  least  common  is  neuralgia. 

I  may  fairly  hope  to  be  acquitted  of  any  predisposition  to  lay 
exaggerated  stress  on  this  kind  of  influence  in  the  production 
of  neuralgia,  considering  all  that  I  have  said  of  the  import- 
ance of  that  inevitable  cause,  the  neurotic  inheritance,  and  all 
that  I  shall  have  to  say  presently  as  to  the  effects  of  a  variety 
of  external  influences  of  a  totally  different  kind.  But  I  con- 
fess that,  with  me,  the  result  of  close  attention  given  to  the 
pathology  of  neuralgia  has  been  the  ever-growing  conviction 
that,  next  to  the  influence  of  neurotic  inheritance,  there  is  no 
such  frequently  powerful  factor  in  the  construction  of  the 
neuralgic  habit  as  mental  warp  of  a  certain  kind,  the  product 
of  an  unwise  education.  This  Work  is  not  intended  as  a 
treatise  either  on  religion  or  psychology,  and  yet  it  is  impos- 
sible for  me  to  avoid  some  few  words  that  may  seem  to  trench 
on  the  province  of  each  :  for  I  believe  that  there  are  certain 
emotional  and  spiritual  and  intellectual  grooves  into  which  it 
is  only  too  easy  to  direct  the  minds  of  young  children,  and 
which  conduct  them  too  often  to  a  condition  of  general  ner- 
vous weakness,  and  not  unf  requently  to  the  special  miseries  of 
neuralgia.  As  regards  the  working  of  the  intellect,  it  is  easier 
to  speak  in  a  free  and  unembari'assed  manner  than  respecting 
the  other  matters.  There  can  be  no  doubt  that,  of  intellectual 
work,  that  sort  which  exhausts  and  harrasses  the  nervous  sys- 
tem is  the  forced,  the  premature,  and  the  unreal  land;  and  this 
it  is  which  predisposes,  among  other  nervous  maladies,  to  neu- 
ralgia. It  is  more  difficult  to  sj)eak  the  truth  about  emotional 
influences  generally,  and  especially  about  those  which  are 
concerned  with  the  highest  spiritual  matters  ;  but  I  should  do 
wrong  were  I  to  suppress  the  statement  of  my  convictions  on 
this  point.  I  beheve  that  a  most  unfortunate,  a  positively  poi- 
sonous influence  upon  the  nervous  system,  especially  in  youth, 
is  the  direct  result  of  efforts,  dictated  often  by  the  highest 
motives,  to  train  the  emotions  and  aspirations  to  a  high  ideal, 
esijecially  to  a  high  religious  ideal.  It  is  not  the  object  that  is 
bad,  but  the  machinery  by  which  it  is  sought  to  be  attained. 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  109 

In  modern  society  there  are  two  principal  methods  which  are 
popularly  employed  for  this  purpose  ;  I  shall  describe  them, 
by  two  epithets  which  are  selected  with  no  olfensive  mtention, 
as  the  Conventual  and  the  Puritan  methods  of  spiritual  train- 
ing. By  the  former  is  meant  that  kind  of  education  which 
deliberately  dwarfs  the  nervous  energy,  with  tlie  hope  of  pre- 
serving the  mind  from  the  contamination  of  unbelief  and  of 
sinful  passion.  It  is  a  system  which  is  not  peculiar  to  the 
Roman  Church,  nor  even  to  the  Christian  religion,  and  it  need 
the  less  detain  our  attention,  as  its  effects,  so  far  as  they  are 
evil,  are  mainly  seen  in  general  nervous  and  mental  enfeeble- 
ment,  rather  than  in  the  outbreak  of  explosive  nervous  dis- 
orders, such  as  convulsion,  insanity,  or  neuralgia.  There  are 
doubtless  exceptions  to  tlie  rule  ;  but  that  is  the  rule.  It  is  far 
otherwise  with  the  si^iritual  education  which  is  here  called 
Puritan,  but  which  is  confined  to  no  party  in  tlie  Church.  This 
is  a  system  which  seeks  to  purify  and  exalt  the  mind,  not  by 
enforcing  obedience  to  a  series  of  spiritual  rules  for  which 
another  mind  is  responsible,  but  by  compelling  it  to  a  perpet- 
ual introspection  directed  to  the  object  of  discovering  whether 
it  comes  up  to  a  self-erected  spiritual  standard.  The  reader 
will  understand  that  I  have  not  the  remotest  intention  to 
depreciate  either  a  true  and  manly  self-restraint  in  obedience 
to  the  direction  of  "  pastors  and  masters,"  or  an  honest  watch- 
fulness over  one's  own  conduct  and  thoughts.  But  the  lessons 
wliich  our  psychologists  are  rapidly  leai-ning,  as  to  the  evil 
effects  on  the  brain  of  an  education  that  promotes  self -con- 
sciousness, are  sorely  needed  to  be  applied  to  the  pathology  of 
nervous  diseases  generally,  and  of  neuralgia  among  the  rest. 
Common  sense  and  common  humanity,  when  united  with  the 
physician's  knowledge,  cry  out  against  the  system  under  which 
religious  parents  and  teachers  subject  the  feeble  and  highly 
mobile  nervous  systems  of  the  young  to  the  tremendous  strain 
of  spiritual  self-questioning  upon  the  most  momentous  topics. 
More  especially_  is  such  a  practice  to  be  condemned  in  the  case 
of  boys  and  girls  who  are  passing  through  tlie  terrible  ordeal 
of  sexual  development — an  epoch  which,  as  we  have  already 
seen,  is  peculiarly  favorable  to  the  formation  of  the  neurotic 
habit,  and  I  must  eraphatically  state  my  belief  that  among  the 
seriously-minded  English  middle  classes,  more  especially, 
whose  life  is  necessarily  colorless  and  monotonous,  the  mis- 
chief thus  worked  is  both  grave  and  widely  spread. 

Perhaps  the  maximum  of  damage  that  can  be  inflicted 
through  the  mind  upon  the  sensory  nervous  centres  is  effected 
when  to  the  kind  of  self -consciousness  that  is  generated  by  an 
excessive  spiritual  introspection  there  is  added  the  incessant 
toil  of  a  life  spent  in  sedentary  brain  work,  and  checkered 
with  many  anxieties,  and  many  griefs  which  strike  through  the 
affections.     Doubtless,  such  a  combination  of  morbid  mental 


110  PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA. 

influences  is  sufficient  of  itself  to  generate  the  neuralgic  dispo- 
sition in  its  severest  forms,  without  any  hereditary  neurotic 
influence,  and  without  any  other  peripheral  irritations  ;  I  have 
more  than  one  such  instance  in  my  mind  at  this  moment.  But, 
if  they  can  do  this,  much  more  can  such  influences  arouse 
inherent  tendencies  to  neuralgia  ;  to  pei'sons  who  are  predis- 
posed in  this  manner  they  are  most  highly  deleterious. 

8.  We  come  now  to  the  peripheral  influences  which  i'n  a 
more  obvious  manner  become  factors  in  the  production  of  neu- 
ralgia. Of  such  mfluences  there  are  an  immense  variety,  and 
the  only  com m  mi  quality  that  can  be  predicated  of  all  is  the 
tendency  dhectly  to  depress  the  life  of  the  sentient  centre  upon 
which  their  action  impinges. 

If  we  search  among  the  external  influences  which  contribute 
to  the  production  of  neuralgia  for  one  that  is  apparently  trivial 
as  to  the  amount  of  material  disturbance  which  it  can  cause, 
and  yet  is  very  frequently  effective,  we  may  select  the  agency 
of  cold.  The  efliect  of  a  continuous  cold  draught  of  air  imping- 
ing on  the  naked  skin  for  some  thne  is  comparatively  frequently 
seen  in  the  provocation  of  neuralgic  attack  :  we  say  compara- 
tively, because  this  influence  is  more  frequently  effective 
than  blows,  wounds,  or  temporary  irritations  of  any  kind, 
applied  to  the  peripheral  ends  of  sensory  nerves .  But  if  neu- 
ralgia be  a  more  frequent  consequence  of  cold  than  of  these 
other  influences,  a  moment's  reflection  will  show  that  it  is  by 
no  means  an  absolutely  common  result.  One  has  only  to 
think  of  the  numerous  omnibus-drivers,  engine-drivers,  cab- 
drivers,  etc.,  etc.,  who  pass  their  whole  working  lives  in  pre- 
senting the  (more  or  less)  naked  expanse  of  their  trigeminal 
and  their  cervico-occipital  nerves  to  every  variety  of  wind,  to 
to  perceive  that,  were  this  sort  of  influence  very  potent  in  itself, 
male  neuralgic  patients  should  swarm  as  thick  as  bees  in  our 
hospital  and  dispensary  out-patient  rooms ;  which  is  notoriously 
quite  contrary  to  the  fact.  The  same  remarks,  in  both  direc- 
tions, may  be  aj)i)lied  to  the  direct  influence  of  atmospheric 
moisture,  either  with  or  without  the  effect  of  wind  (of  course 
I  am  not  speaking  of  the  more  recondite  effects  of  damp  soil  on 
the  persons  who  live  about  it.  [Among  the  huDclred  patients 
who  formed  the  basis  of  the  inquiries  mentioned  in  this  work, 
forty-one  accused  external  cold  of  producing  the  attack,  but 
many  of  these  produced  insufficient  evidence  that  such  was 
the  case.]  In  short,  the  direct  effects  of  atmospheric  cold 
would  seem  to  be  these.  Mere  lowness  of  temperature  goes  for 
something,  but  not  much ;  [The  most  mai'ked  instance  of  the 
effect  of  cold,  per  se,  that  I  have  seen,  was  exhibited  by  a 
young  lady  who  was  under  my  care  during  the  past  severe 
winter  (1870-71).  During  much  of  the  time  she  was  confined 
to  a  carefully- warmed  apartment,  on  penalty  of  a  violent  par- 
oxysm if  she  left  it.]    for  about  as  much,  perhaps,  as  it  does  in 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  Ill 

tlie  way  of  aggravating  all  neurotic  tendencies.  Cold  joined 
with  wind  is  much  more  powerful.  And  the  maximum  of 
ill-elf ect  seems  reached  by  very  cold  wind  mingled  with  sleet 
or  driving  rain,  which  keeps  the  skin  soddon.  F>ut  the  con- 
clusion at  which  I  long  ago  arrived  is,  that  none  of  these 
influences  ever  take  more  than  a  small  (though  it  is  sometimes 
an  imx3ortant)  part  in  the  production  of  neuralgia ;  and  that  in 
the  majority  of  cases  there  is  no  pretence  for  supposing  that 
they  had  the  slightest  share  in  its  causation. 

A  word  or  two  must  be  said  as  to  the  modus  operandi  of 
cold  and  cold  wind,  as  these  are  the  most  frequent  of  external, 
so-called  "  exciting  "  causes.  The  popular  use  of  such  phrases 
as  the  latter  has  an  extraordinary  influence  in  disguising  the 
plain  fact,  which  is,  that  these  influences  operate  wholly  in  the 
direction  of  robbing  the  nerves  of  force.  The  continuous 
abstraction  of  heat  from  the  sui-face,  which  of  course  is  mater- 
ially aided  by  rapid  movement  of  the  air,  must  necessitate  a 
readjustment  of  the  distribution  of  energy,  the  only  result  of 
which  must  be  to  drain  the  sensory  nervous  centre  of  its  reserve 
of  force.  But,  in  fact,  there  is  an  experiment,  ready  performed 
to  our  hands,  which  may  amply  satisfy  us  as  to  the  kind  of 
influence  exerted  by  colcl  on  superflcial  nerves,  viz. ,  the  sensa- 
tions exiaerienced  in  recovering  from  frost-bite,  which  has  been 
severe  enough  to  paralyze  the  nerves  without  causing  actual 
gangrene  of  the  tissues.  The  passage  of  the  nerves  back  from 
temporary  death  to  full  functional  life  is  marked  by  a  half-way 
stage  in  which  there  is  agonizing  pain. 

4.  We  must  next  consider  the  effects  of  a  class  of  peripheral 
influences  which  act,  where  they  exist,  in  a  more  constant 
manner  than  any  others;  viz.,  those  in  which  the  trunk  or 
periphery  of  a  sensory  nerve  either  receives  a  severe  injury,  or 
becomes  more  or  less  engaged  in  inflammatory  processes,  or 
compressed  or  otherwise  damaged  by  the  growth  of  tumors  or 
the  spread  of  destructive  ulcerations. 

With  regard  to  ordinary  nerve-wounds  as  a  cause  of  neu- 
ralgia, we  have  already  said  (vide  Chapter  II.)  nearly  as  much 
as  it  is  necessary  to  say ;  we  need  only  here  point  out  that,  like 
the  influence  of  cold  applied  to  superficial  nerves,  that  of 
wounds  must  necessarily  be  a  depressing  one  to  the  centre  with 
which  the  wounded  nerve  is  connected,  and  the  resulting  neu- 
ralgia must  be  regarded  as  an  expression  of  impeded  and 
imperfect  nerve-energy,  not  of  heightened  nerve-function. 
The  pain  is  set  up  during  the  process  of  nerve-healing;  that  is 
to  say,  at  a  stage  intermediate  between  those  of  abolished  func- 
tion and  completely  restored  function;  and  there  can  be  little 
doubt  that  the  obstinacy  with  which  it  is  often  protracted  is 
due  to  the  slowness  with  which  a  wounded  nerve  recovers 
its  full  functional  activity ;  when  once  the  latter  is  completely 
restored  there  is  an  end  of  neuralgic  pain.  It  is  exactly  ana- 
logous to  the  course  of  events  in  recovery  from  freezing. 


112  PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA. 

There  remain  for  consideration,  however,  (a)  a  small  class 
of  cases  of  nerve-wounds  in  which  the  healing  jjrocess  is  not 
simx^le;  but  the  lesion  is  followed  hy  the  development  of  a 
tumor  of  the  kind  denominated  true  neuroma.  The  process 
consists  of  h3q^)erplastic  changes  in  the  nerve-fibres;  its  com- 
monest examples  are  seen  in  the  extraordinarOy  painful  swel- 
lings that  occur  on  the  ends  of  nerves  left  in  stumps  after 
amputations ;  but,  in  fact,  a  neuroma  of  this  kind  may  occur 
after  any  kind  of  severe  nerve-injury,  as,  e.  g.,  a  cut  from 
broken  glass,  the  impaction  of  foreign  bodies,  etc.  The  true 
neuromata  are  composed  mainly  of  nerve-tissue,  with  a  rela- 
tively small  element  of  connective  tissue :  the  nerve-fibres  can 
be  traced  directly  to  the  nerve-tumor.  Besides  the  traumatic 
neuromata  which  form  permanent  tumors,  incapable  of  being 
got  rid  of  except  by  actual  excision,  a  minor  variety  of  the 
same  kind  of  change  has  in  several  cases  been  known  to  take 
place  in  consequence,  of  an  abiding  local  irritation  from  the 
imj)action  of  a  foreign  body,  on  the  removal  of  which  the 
neuromatoid  enlargement  completely  disappeared,  (b)  There 
are  likewise  a  certain  number  of  cases  in  which  a  tumor  is 
developed  from  the  neurilemma,  and  does  not  consist  of  nervous 
tissue ;  these  are  distinguished  as  false  neuromata,  and  may  be 
of  various  kinds,  the  fibromatous  and  gliomatous  being  far  the 
most  common,  but  cysts  and  cystic  tumors  also  sometimes 
occurring. 

The  case  of  the  neuromata  is  well  worth  reflecting  upon,  in 
the  course  of  our  endeavors  to  clear  up  the  Pathology  and 
Etiology  of  Neuralgia.  If  ever  we  could  find  a  merely  peri- 
pheral influence  which  would  of  itself  be  invariably  competent 
to  excite  neiu'algic  pams,  it  would  surely  be  found  in  neuroma ; 
but  the  case  is  not  merely  not  so,  it  is  strikingly  contrary. 
Just  as  wounded  and  inflamed  nerves  frequently  go  through 
the  whole  processes  of  disease  and  recovery  without  once 
eliciting  a  neuralgic  pang,  so  is  it  with  neuromata;  they  are 
not  unfrequently  quite  ind.olent,  and  neither  excite  neuralgia, 
nor  are  themselves  at  all  particularly  tender  to  the  touch. 
And  what  is  most  remarkable  is,  that,  as  Eulenburg  correctly 
remarks,  among  the  pseudo-neuromata  the  kind  of  tumoy 
which  is  most  frequently  associated  with  neuralgia  is  by  no 
means  the  dense  fibroma  or  glioma,  which  mig]it  bo  expected 
by  its  mechanical  pressure  to  excite  inevitable  neuralgic  pain, 
but  the  far  softer  and  more  yielding  cystic  tumors.  I  do  not 
know  how  the  facts  may  affect  the  reader,  but  to  me  they  sug- 
gest the  strongest  possible  arguments  against  the  belief  that 
peripheral  irritation  can  of  itself  produce  neuralgia  without 
the  intervention  of  some  centric  change.  The  tendency  to  such 
change(from  inherent  constitution)  in  the  sensory  root  of  the 
nerve  must  surely  be  the  reason  ^vhy  neuroma  causes  neuralgia 
in  a  given  number  of  subjects,  instead  of  letting  them  go  seot- 
Iree,  as  it  does  other  persons. 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  113 

Tlie  same  remarks  apply  to  the  result  of  observations  on  th  e 
effect  of  tumors  commencing  in  tissues  altogether  unconnected 
with  the  nerve,  and  merely  coming  to  involve  it,  secondarily, 
in  pressure.  It  has  been  often  noted  that,  among  these  tumors, 
fluid-containing  cysts  and  soft  medullary  cancers  are  far  more 
frequently  the  cause  of  decided  and  distressing  neuralgia  than 
the  denser  and  less  yielding  neoplasms.  Of  kinds  of  tumors 
that  are  specially  apt  to  produce  severe  and  even  intolerable 
neuralgia  by  the  jsressure  on  nerves,  it  has  been  remarked  that 
aneurisms  are  among  the  worst :  here  every  pulsation  often 
sends  a  dart  of  agony  through  the  nerve.  There  is  a  reason 
here,  hov/ever,  which  is  often  left  out  of  sight ;  not  mei^ely  is 
the  perpetually  varying  pressure  specially  harassing  and 
exhausting  to  the  nerve,  but  in  many  of  these  cases  there  is 
genera,l  arterial  degeneration,  and  the  sensory  root  of  the  nerve 
is  exceedingly  likely  to  be  very  badly  nourished.  [This  result 
will  be  more  directly  brought  about  when  the  aneurism 
happens  to  press  on  the  ganglion  of  a  posterior  root.]  We  pass 
now  to  the  consideration  of  the  influence  exerted  by  other 
great  series  of  perijoheral  impressions  in  the  production  of  neu- 
ralgia. These  impressions  are  connected  chiefly  with  the  func- 
tions of  the  digestive  and  of  the  genito-urinary  organs,  tne 
functions  of  the  eye,  and  the  nutrition  of  the  teeth. 

To  take  the  least  important  of  these  first,  I  may  surprise 
some  readers  by  the  stateinent,  which  I  nevertheless  make  with 
much  confidence,  that  irritation  of  any  part  of  the  alimentary 
canal  is,  on  the  whole,  a  rare  concurrent  cause,  even  in  the 
production  of  neuralgia.  There  are,  as  has  been  already  fully 
explained,  cases  of  neuralgia  seated  in  these  viscera  themselves 
^or  the  plexuses  in  their  immediate  neighbourhood),  although 
their  number  is  immensely  smaller  than  that  of  the  neuralgias 
of  superficial  nerves.  But  it  is  not  at  all  common — it  is  even 
exceedingly  rare — for  irritation  conveyed  from  the  alimentary 
canal  to  take  any  important  part  in  setting  up  neuralgia  of  a 
distant  nerve,  even  when  that  nerve  has  close  connections, 
through  the  centres,  with  those  coming  from  the  irritated  por- 
tion of  the  alimentary  canal.  Valleix  had  the  great  merit  to 
perceive  this,  even  in  the  case  of  neuralgias  of  the  head,  where 
appearances  are  so  likely  to  lead  the  observer  to  a  contrary 
opinion.  And  it  is  not  a  little  remarkable  that  this  should  be 
the  case,  when  we  consider  the  close  central  connections  which 
the  vagus,  the  great  sensory  nerve  of  a  large  portion  of  the 
alimentary  canal,  has  with  the  sensory  root  of  the  trigeminus. 
In  fact,  however,  there  are  certain  peculiar  forms  of  gastric 
irritation  which  do  react  upon  the  trigeminus ;  for  instance,  a 
lumj)  of  unmelted  ice,  suddenly  swallowed,  almost  invariably 
produces  acute  pain  in  the  supra-orbital  branch  of  the  fifth,  on 
one  side  or  the  other,  and  occasionally  (as  in  a  case  cited  by  Sir 
Thomas  Watson)  in  other  nerves,  But  that  common  dyspeptic 


114  PATHOLOGY  AND  ETIOLOGY  OF  NEURALGL4.. 

troubles  at  all  frequently  or  importantly  contribute  to  tbe  pro- 
duction of  neuralgia,  I  do  not  for  a  moment  believe :  it  needs 
some  very  powerful  irritation,  such  as  that  just  mentioned,  or 
as  impaction  of  great  masses  of  scybala^  in  the  intestines,  or 
severe  irritation  from  worms,  to  produce  such  an  effect. 

It  is  far  otherwise  with  the  genito-uriuary  apparatus;  in  a 
large  number  of  cases,  irritations  proceedmg  from  these  organs 
do  undoubtedly  contribute  to  the  production  of  neuralgia, 
though  by  no  means  in  the  important  degree  which  many 
authors  seem  to  have  assumed.  There  can  be  no  doubt,  for 
examj)le,  that  the  irritation  of  a  calculus,  either  within  the 
kidney  itself,  in  the  ureter,  or  in  the  bladder,  may  set  up  vio- 
lent neuralgia,  which  for  the  most  part  is  localized  in  the 
branches  of  the  lumbo-abdominal  nerves.  The  instance  of  the 
eloquent  Eobert  Hall  is  an  example  of  renal  calculous  acting 
in  this  way:  he  suffered  the  most  excruciatmg  agony  for 
years,  and  was  obliged  to  take  enormous  quantities  of  opium 
in  order  to  make  life  endurable.  An  instance  of  calculus 
impacted  in  the  ureter,  in  a  gentleman  somewhat  past  middle 
age,  occurred  in  my  o\vn  practice;  the  lumbo-abdommal  neu- 
ralgia occurred  m  frequent  paroxysms  of  dreadful  severity ; 
and  another  case,  already  referred  to  was  that  of  a  woman, 
in  whom  ovarian  neuralgia  was  undoubtedly  in  great  part 
due  to  the  ii-ritation  of  an  impacted  calculus  m  the  ureter. 
These  cases,  however,  are  very  rare  in  comparison  with  others 
in  which  the  peripheral  source  of  the  neuralgia  is  either  the 
uterus  or  ovary,  or  the  external  genitals.  I  have  no  means  of 
ascertaining,  with  anything  like  accuracy,  the  frequency  with 
which  the  internal  sexual  organs  are  the  starting-point  of  neu- 
ralgia, because  the  majority  of  such  cases  pass,  naturally,  to 
the  care  of  physicians  who  practice  chiefly  in  the  diseases  of 
women,  and  consequently  not  adequately  represented  either  in 
my  hospital  or  my  private  practice ;  still,  I  have  seen  a  good 
many  of  these  affections,  and,  though  I  speak  with  the  reserve 
necessitated  by  the  circumstances  just  named,  I  am  much 
inclined  to  believe  that  even  such  powerful  centripetal  influ- 
ences as  those  of  the  states  of  commencing  puberty,  of  preg- 
nancy, of  the  change  of  life,  and  uterine  diseases  generally,  are 
very  rarely  the  cause  of  true  unilateral  neuralgia,  except  in 
subjects  with  congenital  tendencies  to  neuralgia.  But  in  pre- 
disposed subjects  there  can  be  no  doubt  that  these  influences 
assist  most  powerfully  in  producing  the  malady. 

Of  the  power  of  irritation  of  the  external  genitalia  to  act  as 
a  so-called  "exciting  cause"  of  neuralgia,  there  is  abundant 
evidence.  I  would  especially  call  attention  to  the  remarka- 
ble monograph  of  M.  Mauriac,  [''Etude  sur  les  Nevralgies 
Reflexes  symptomatiques  de  V Orclu-epididymite  hlenorrha- 
gique'^  Par  C.  Mauriac,  Medecm  de  FHospital  du  Midi.  Paris, 
1870.]  on   the   neuralgias  consecutive   to  blenorrhagic  orclii- 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  115 

epididymitis,  as  illustrating  this  with  a  force  that  was  to  me, 
for  one,  surprising.  I  shall,  perhaps,  have  further  occasion  to 
these  researches ;  here  it  will  be  enough  to  mention  that  M. 
Mauriac's  enormous  experience  of  blenorrhoea  and  orchitis  at 
the  Midi  has  shown  that,  in  an  exceedingly  large  number  of 
cases,  certainly  not  less  tlifm  four  per  cent. ,  this  combination 
is  followed  by  reflex  neuralgias,  of  which  a  large  number  are 
not  seated  in  the  genital  apparatus,  but  affect  the  track  of  some 
distant  sensory  nerve,  though  the  intermediation  of  the  spinal 
centres ;  and  that  with  these  reflex  pains  there  is  often  pro- 
found general  disturbance,  including  very  often  an  extremely 
profound  general  aneemia.  The  most  frequent  kind  of  these 
neuralgias  is  rachialgia,  i.  e.,  pain  in  the  superficial  posterior 
branches  of  spinal  nerves ;  next  comes  lumbo-abdominal  neu- 
ralgia; then  sciatic  and  crural,  visceralgic  (abdominal),  etc.; 
and  besides  all  these. there  are  numerous  instances  of  neuralgia 
in  the  testis.     As  to  the  nervous  "  reflection,"  more  hereafter. 

It  has  surprised  me,  somewhat,  that  while  M.  Mauriac  has 
seen  so  many  reflex  neuralgias  set  up  by  orchi-epididymitis,  he 
does  not  appear  to  have  noticed  cases  of  trigeminal  neuralgia 
from  this  source ;  because,  in  the  very  analogous  instance  of 
the  peripheral  irritation  produced  by  excessive  masturbation, 
we  undoubtedly  do  frequently  get  a  development  of  the  ten- 
dency to  migraine,  and  also  to  other  forms  of  neuralgia  of  the 
fifth :  moreover  the  effect  of  such  local  irritation  can  be  occa- 
sionally traced  witli  much  distinctness  in  the  trigemini,  by  a 
tendency  to  certain  forms  of  eye-disease  without  positive  neu- 
ralgia. This  was  remarkably  exemi^lified  in  a  case  which  was 
under  my  care  some  years  ago,  and  in  which  both  eyes  were 
greatly  damaged  by  vaso-motor  and  trophic  changes ;  partial 
insanity  also  supervened  with  hallucinations  of  sight  and  hear- 
ing. 

We  come  now  to  one  of  the  most  powerful  sources  of  peri- 
pheral irritation  tending  to  set  up  neuralgia;  viz.,  functional 
abuse  of  the  eye.  This  is  one  of  the  very  few  peripheral  influ- 
ences which  occasionally  we  see  j)roducing  neuralgia  unaided 
by  hereditary  x^redisposition,  or  any  other  observable  cause 
whatever,  and  in  a  far  larger  number  producing  it  with  the 
sole  aid  of  more  or  less  defective  general  nutrition.  The  latter 
occurrence  is  well  exemplified  by  a  case  which  Mr.  Carter  sent 
me  the  other  day,  and  which  also  illustrates  (second  attack)  the 
effect  of  the  Saperaddition  of  syphilitic  taint: 

Matilda  W ,  aged  thirty-three,  married,  and  has  three 

very  healthy  children.  Comes  of  a  remarkably  healthy  fam- 
ily, of  which  she  told  me  the  entire  history  for  three  genera- 
tions, with  unusual  intelligence  and  clearness.  No  neuroses, 
properly  so-called,  in  any  of  her  relatives  during  all  this  time. 
She  herself  was  a  very  strong  and  hearty  girl  until  the  age  of 
seventeen;  between  this  date  and  her  marriage,  three  years 


116  PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA. 

later,  she  was  obliged  to  work  tremendously  hard  at  fine  sew- 
ing, by  which  means  she  gained  a  very  scanty  livelihood. 
After  a  comparatively  short  period  of  this  woi-k  she  began  to 
suffer  from  typical  attacks  of  migraine,  very  severe,  and  recur- 
ring every  three  or  four  weeks,  but  in  no  particular  connection 
with  the  menstrual  function,  which  was  normal.  On  her 
marrying  and  ceasing  to  do  needle- work,  the  migraine  entirely 
disappeared,  and  she  retained  perfect  health  till  the  commence- 
ment of  1871.  At  this  time  she  had  suckled  a  very  hearty 
baby  for  ten  months,  and  was  not  able  to  furnish  such  good 
living  as  usual.  She  was  attacked  early  in  January,  with  vio- 
lent neuralgia  affecting  all  three  branches  of  the  right  fifth,  and 
she  the  more  readily  applied  for  advice  because  she  soon  found 
that  the  neuralgia  was  becoming  complicated  with  dimness  of 
vision  in  the  eye  of  the  affected  side,  ' '  as  if  she  was  going  to 
have  a  cast."  Was  quite  unconscious  of  ever  having  had 
syphilis.  The  medical  man  encouraged  to  believe  that  tlie 
w^hole  malady  was  nervous,  and  would  soon  disappear  under 
appropriate  remedies,  and  gave  her  quinme,  under  which 
treatment  she  declares  that  she  was  rapidly  improving,  both  as 
to  pain  and  vision,  but  that  her  resources  came  to  an  end,  and 
she  could  no  longer  pay  for  the  medicine.  She  then  neglected 
herself,  and  rapidly  got  worse  in  all  regards,  till  at  last  she 
was  compelled  to  apply  to  the  South  London  Ophthalmic  Hos- 
pital, whence  Mr.  Carter  sent  her  to  me,  on  the  6th  of  April. 
At  this  time  the  paroxysms  were  excessively  violeut  and  fre- 
quent, though  brief.  On  examination,  tender  points  were 
found  at  the  supra-orbital  notch,  at  the  mfra-orbital  foramen; 
in  front  of  the  ear ;  in  the  temjjoral  region ;  in  the  parietal 
region,  and  the  inferior  dental  region.  There  was  strongly 
marked  ansesthesia  of  the  skin  of  the  right  half  of  the  face, 
of  the  gums,  and  of  the  side  of  the  tongue.  The  teeth 
were  absolutely  perfect :  not  one  spot  of  caries  could  be  seen. 
Taste  was  completely  destroyed  in  left  half  of  anterior  part  of  the 
tongue.  Smell  was  totally  lost  on  both  sides,  and  had  been  so, 
the  woman  declared,  from  a  very  early  period  in  the  illness. 
The  right  eye  sliowed  complete  paralysis  of  the  levator  pal- 
pebra3  and  of  the  external  rectus ;  nearly  complete  paralysis  of 
the  superior  and  inferior  rectus,  rather  less  marked  paralysis 
of  the  internal  rectus.  Pupil  normal,  conjunctiva  mod- 
erately congested,  lachrymation  jjrofuse,  photophobia  par- 
tial. The  functions  of  the  retina  were  perfect.  Accommoda- 
tion was  affected  in  the  following  degi'ee  and  manner .  The 
vision  of  the  affected  eye  was  perfect  at  long  distances, 
very  imperfect  at  short  distances.  With  both  eyes  open 
she  saw  every  thing  double,  but  could  still  cou.nt  all 
the  bricks  in  a  whitewaslied  wall  at  sixteen  feet  dis- 
tant. There  was  no  secondary  disturbance  of  the  stomach 
whatever.     On  the  first  visit  she  assuredly  had  no  visible  signs, 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  ll/ 

in  skin  or  throat,  of  syphilis ;  the  perfect  health  of  her  chil- 
dren, and  absence  of  abortions,  made  syphilis  the  less  probable. 
But  on  her  second  visit  she  complained  of  sore  throat,  and  a 
week  later  a  palpably  specific  sore  appeared  on  the  soft 
palate.  She  declared,  with  apparent  sincerity,  that  it  was  the 
first  symptom  of  the  kind  she  had  ever  had.  The  neuralgia 
rapidly  disappeared  under  thirty  grains  of  iodide  of  potassium 
daily.  The  lesions  of  taste  and  smell  disappeared  exactly  paii 
passua  with  the  trig-emuial  pains.  The  ocular  paralysis 
threaten  to  be  much  slower  in  departing.  I  think  we  must 
believed  that  this  woman  contracted  syphilis  after  the  birth  of 
her  last  child.  It  is  at  any  rate  certain  that  the  migraine  of 
her  youth  was  perfectly  unconnected  with  syphilis,  oeing  as 
unlike  the  pains  evoked  by  the  latter  as  it  is  possible  for  two 
kinds  of  pain  to  be.  In  all  probability  she  was  infected  during 
her  last  lactation. 

Last  among  the  peripheral  influences  of  sufficient  importance 
to  be  specially  mentioned  as  effective  factors  in  the  pi'oduction 
of  neuralgia,  must  be  mentioned  caries  of  the  teeth,  and  the 
comparatively  rare  accident  of  the  mal-position  or  abnormal 
growth  of  a  "wisdom-tooth."  It  is  an  undoubted  fact  that 
these  things  may  cause  neuralgia  even  of  a  very  serious  type, 
and  attended  with  extensive  complications  ;  as  in  Mr.  Salter's 
cases,  already  mentioned,  of  reflex  cervico-brachial  neuralgia 
from  carious  teeth.  Looking  to  the  extreme  frequency  of 
caries,  however,  as  compared  with  the  rarity  of  true  neuralgia 
(not  mere  toothache)  as  a  consequence  of  it,  it  is  impossible 
not  to  suppose  that  the  share  of  the  carious  teeth  in  the  produc- 
tion of  such  neuralgia  must  be  very  small,  compared  with  that 
of  other  influences. 

5 .  Tlie  next  influence  which  we  shall  mention  as  undoubt- 
edly very  effective  in  assisting  the  production  of  neuralgia  in 
certain  cases  is  that  of  angemia  and  mal-nutrition  generally ; 
but  it  is  not  necessai-y  to  dwell  on  this  at  any  length.  The 
fact  is  notorious  that  severe  loss  of  blood  is  always  followed 
by  headache ;  and  if  there  be  the  least  predisiDOsition  to  neu- 
ralgia, this  headache  will  very  commonly  take  the  form  of  the 
severest  clavus.  And,  in  like  manner,  chronic  states  of  anae- 
mia and  of  mal-nutrition  undoubtedly  aggravate  every  existing 
neuralgia,  and  bring  out  lurking  tendencies  to  the  disease. 
But  I  do  not  believe  that  anaemia,  or  starvation  pure  and  sim- 
ple, ever  generates  true  neuralgia  by  its  sole  influence . 

6.  The  question  how  far,  and  in  what  way,  the  neuralgic 
tendency  is  helped  by  certain  constitutional  diatheses,  such  as 
rheumatism  and  gout,  and  by  certain  toxa3mia3.  such  as  malaria 
alcoholism,  lead-poisoning,  etc.,  is  a  very  much  more  difficult 
one  than  might  be  supposed  from  the  off-hand  manner  in 
which  many  writers  speak  of  the  "rheumatic,"  the  "gouty," 
or  the  "alcoholic"  forms  of  "neuralgia."    We  may,  however, 


118  PATHOLOGY  AND  ETIOLOGY  OP  NEURALGIA. 

simplify  it  a  good  deal.  In  tlie  first  place,  it  seems  obvious  to 
m.e  that  the  only  manner  in  which  alcohol  helps  the  iDi'oduc- 
tion  of  true  neuralgia  is  by  its  tendency,  after  long  abuse,  to 
produce  degeneration  of  the  nervous  centres :  it  will  therefore 
be  considered,  shortly,  under  another  division  of  the  present 
subject.  Tjead-poisioning,  again,  only  produces  so  highly 
special  a  form  of  neuralgia  (if  colic  be  neuralgia  at  all)  that  it 
need  not  detain  us  here.  The  influence  of  malaria  is,  for  the 
most  part,  an  utter  mystery  to  us,  but  by  so  much  as  v/e  can  see 
it  appears  plain  that  one  of  the  most  important  features  in  the 
disease  is  a  powerful  disturbance  of  the  spinal  vaso-motor  cen- 
tres. But  the  most  interesting  consideration  that  we  have  to 
deal  with  is  the  question  of  the  supposed  relations  of  the  rheu- 
matic and  the  gouty  diatheses,  and  the  syphilitic  dyscrasia,  to 
the  neuralgic  tendency.  On  this  point  I  am  obliged  to  disagi'ee 
in  toto  with  the  popular  view  that  assigns  these  diathe- 
ses among    the    most    frequent  predisposing  causes  of  neural- 

To  take  the  case  of  rheumatism  first,  I  am  willing  to  allow 
that  there  are  a  number  of  facts  which  suj)erficially  appear  to 
countenance  the  idea  of  a  close  connection  of  this  disease  with 
neuralgia.  But  of  these  facts  a,  considerable  projDortion 
consist  only  of  examples  of  inflannnation  of  the  nerve- 
sheath,  with  a  certam  amount  of  effusion  within  and 
around  it,  occurring  in  persons  who  have  never  shown 
any  symptoms  which  warrant  the  assumption  of  a  general 
rheumatic  diathesis  ;  and  these  local  phenomena  really  differ 
in  nothing  from  many  trophic  and  vaso-raotor  changes  which 
have  been  already  described  as  plainly  secondary  to  ordinary 
neuralgia  in  which  there  could  be  no  pretence  of  a  rheumatic 
pathology  except  on  the  slender  foundation  of  a  suspicion 
that  the  afPection  was  immediately  excited  by  the  influence  of 
cold,  which  is  really  no  argument  at  all .  Such  patients  will 
be  found  to  have  exhibited,  not  special  rheumatic,  but  special 
neuralgic  tendencies  in  their  past  history.  On  the  other  hand, 
there  undoubtedly  are  a  certain  number  of  patients  who,  hav- 
ing previously  given  signs  of  a  tendency  to  generalized  rheu- 
matic inflammationof  fibrous  membranes,  are,  on  some  particu- 
lar occasion,  attacked  with  similar  inflammation  extending 
over  a  more  or  less  considerable  tract  (not  a  small  limited  spot) 
of  a  nerve  sheath.  But  so  far  from  agreemg  with  those  who 
think  that  this  is  a  frequent  case,  my  experience  teaches  me 
that  it  is  quite  exceptional ;  nor  do  I  believe  that  the  common 
opinion  could  ever  have  arisen  had  it  not  been  for  the  rage  that 
exists  for  connecting  eveiy  disease  with  a  special  diathesis 
which  the  profession  flatters  itself  that  it  understands .  Few 
persons  have  taken  more  pains  than  myself  to  ascertain  the 
frequency  with  which  neuralgic  patients  show  a  history  of  pre- 
vious rheumatism,  whether  in  the  so-called  "fibrous,"  or  in 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  119 

the  synovial  form ;  but  it  is  remarkable  how  seldom  I  have 
found  this  to  be  the  ease — a  result  which  surprised  me,  because 
it  happened  that  I,  a  neuralgic  subject,  had  suffered  in  youth 
from  regular  acute  rheumatism,  and  had  fancied  that  I  should 
discover  a  close  connection  between  rheumatism  and  neuralgia. 
Eulenburg  states  that  neuralgia  caused  by  cold  more  frequently 
attacks  the  sciatic  nerve  than  any  other,  and  thinks  that  the 
tendency  to  sciatica  is  characteristic  of  the  relations  of  rheu- 
matism to  sensory  nerves.  For  my  own  part,  I  see  no  reason 
to  call  in  the  rheumatic  diathesis  as  a  deus  ex  machina  to  ex- 
plain the  frequency  with  which  sciatica  follows  comparatively 
trifling  peripheral  impressions  like  that  of  cold.  The  true  rea- 
son I  believe  to  be,  that  what  would  have  been  a  slight  and 
trivial  neuralgia  elsewhere,  becomes  a  serious  affection  in  the 
instance  of  the  sciatic  nerve,  by  reason  of  the  strong  muscular 
pressure  end  dragging  which  are  always  going  on  in  the  thigh 
in  locomotion.  I  shall  return  to  this  subject  when  speaking  of 
Treatment. 

As  regards  the  relations,  of  gout  to  neuralgia,  I  can  hardly 
express  my  own  view  better  than  by  quoting  the  words  of 
Eulenburg:*  "Much  more  doubtful  is  the  influence  of  gout, 
which  in  rare  cases,  perhaps,  produces  neuralgia  directly,  by 
means  of  neuritis,  or  by  the  deposit  of  tophus-like  calcareous 
concretions  in  the  nerve-trunks.  Gout  has  been  reckoned  as  a 
great  influence  among  the  causes  of  superficial  neuralgias 
(sciatica),  and  also  of  visceral  neuralgia  (angina  pectoris,  etc.,) 
but  this  influence  is  more  probably  only  an  indirect  one,  opera- 
ting through  circulation  changes  which  are  often  produced  by 
chronic  liver-diseases  or  by  diseases  of  the  heart  and 
vessels,  (e.  g.  Valvular  diseases  and  narrowing  of  the 
coronary  arteries  in  angina)."  To  which  I  will  add  this  argu- 
ment against  any  close  connection  of  gout  Vv^ith  neiiralgia,  that 
it  is  exceedingly  seldom  that  colchicum  effects  any  decided 
good,  a  fact  which  is  as  unlike  the  relations  of  colchicum  to 
true  gout  as  any  thing  could  be.  For,  whatever  may  be  thought 
of  the  advantages  or  disadvantages,  on  the  whole,  of  employ- 
ing colchicum  against  gout,  at  least  no  one  with  any  experience 
will  deny  tliat  in  the  immense  majority  of  cases  of  true  gouty 
pam,  it  gives  rapid  relief  to  the  acute  suffering.  I  doubt  if  it 
ever  t  acts  in  that  way  in  real  neuralgia,  though  I  have 
occasionally  seen  it  apparently  useful  in  a  more  limited  way, 
as  will  be  said  hereafter. 

_  As  regards  the  relation  of  the  sj^ihilitic  dyscrasia  to  neural- 
gia, I  agree  in  general  with  Eulenburg.  "Syphilis,"  he  says, 
' '  may  be  the  direct  cause  of  neuralgia,  either  by  the  de  velop- 

"  Opcit.,  p.  60. 

f  This  opinion  is  somewhat  stronger  than  that  expressed  in  my  arti- 
cle in  the  "  System  of  Medicine."  I  can  only  say  it  is  the  result  of 
much  increased  experience. 


120  PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA. 

ment  of  specific  guTnmata  in  the  nerve-trunks  or  m  the 
centres,  or  by  aroushig-  chronic  ii'ritative  processes  in  the  nerve 
sheaths,  the  membranes  of  the  brain  and  spinal  cord,  or, 
especially,  in  the  bones  and  periosteum  (sj'philitic  osteitis  and 
periostitis).'  The  case  of  periostitis,  however,  is  a  doubtful 
one :  it  may  be  questioned  whetlier  this  affection  (which  will 
be  among  the  diseases  discussed  in  Pai't  II.  of  this  work)  ever 
give  rise  to  true  neuralgia.  Persons  who  are,  by  inheritance, 
highly  predisxjosed  to  neuralgia, may  from  the  mere  general  low- 
ering of  their  health  produced  by  constitutional  syphilis,  become 
truly  neuralgic  simultaneously  with,  or  subsequently  to,  the 
appearance  of  painful  nodes  on  their  bones.  And  as  regards 
the  whols  relations  of  syphilis  to  neuralgia,  I  must,  from  my 
experience,  conclude  that  the  former  is,  after  all,  but  rarely 
concerned  in  the  production  of  the  latter.  S3T)hilis  has  a 
strong,  specialty  for  producing  limited  motor  paralyses,  but  a 
much  weaker  one  for  x^roducing  limited  affections  of  the  sen- 
sory system. 

7.  We  now  come  to  the  discussion  of  a  group  of  momenta 
whose  influence  in  the  production  of  neuralgia  is  at  once  very 
powerful,  and  of  the  highest  significance  as  regards  the  gen- 
eral pathology  of  the  disease.  These  are  the  degenerative 
changes  of  the  arterial  and  capillary  systems  which  are  a  part 
of  the  normal  phenomena  of  old  age,  but  may  occur  at  earlier 
periods  of  life,  in  consequence  either  of  certain  constitutional 
diseases,  especially  gout,  or  of  special  toxic  influences  on  nutri- 
tion, of  w^hich  persistent  alcoholic  excess  is  very  far  the  most 
important. 

The  reader  does  not  need  to  be  told  the  familiar  story  of  the 
degenerative  changes  in  the  vessels  which,  commencing  usually 
some  time  during  the  fifth  decenniad,  by  degrees  convert  the 
elastic  arterial  coats,  and  the  almost  membranou.s  walls  of  the 
capillai'ies,  into  more  or  less  rigid  tubes;  nor  does  he  need  to  be 
mformed  that  the  tendency  of  these  changes,  as  tliej  operate 
in  the  great  motor  and  intellectual  centres,  is  notoriously  to 
produce  innutrition  of  the  tissues  that  depend  for  their  blood 
supply  on  the  aif  ected  vessels,  whence  cerebral  softening  so 
commonly  results.  That  analogous  changes  take  place  in  the 
vessels  supplying  the  spinal  centres  is  certain;  but  it  is  a 
remarkable  fact  that  these  do  not  very  commonly  produce 
motor  paralysis.  "What  they  do  produce  is  rather  a  slow 
enf eeblement  both  of  (spinal)  sensation  and  motion,  but  where 
the  process  of  decay  has  been  prematurely  forced,  or  the  inher- 
itance of  neurotic  weakness  is  very  marked,  the  process  of 
sensorial  decay  (the  decline,  that  is,  of  true  sensorial  function) 
is  apt  to  be  mingled  wdth  pain.  That  this  pain  should  be 
localized,  often  in  a  single  nerve,  is  no  more  surprising  than  the 
fact  that  the  degenerative  process  itself  should  var^-  so  greatly  in 
the  deo-ree  of  its  development  at  one  point  from,  that  which  it 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  121 

shows  at  others.  I  have  already  insisted  (vide  Chapter  I .)  on  the 
marked  correspondence  between  the  period  of  hfe  in  which 
degenerative  changes  commence  and  progress  (the  last  third, 
roughly  speaking,  of  a  fairly  long  life),  and  that  in  which  the 
most  severe,  intractable,  and  progressively  increasing  neural- 
gias are  developed.  I  must  here  notice  a  singular  statement  of 
Eulenburg's,  that  neuralgia  never  attacks  people  who  are  over 
seventy.  That  statement  shows  that  persons  of  a  greater  age 
than  seventy  are  rare  in  this  world,  and  that  no  such  patient 
happened  to  come  under  Eulenbui-g's  notice ;  for  I  have  (by 
mere  chance,  doubtless)  seen  several  instances  of  first  attacks 
occurring  after  seventy ;  and  almost  the  worst  case  of  epilepti- 
form tic  I  ever  saw  began  when  the  patient  was  eighty ;  she  was 
a  member  of  a  highly  neurotic  family  whose  medical  geneal- 
ogy is  given  at  a  previous  page.  In  general  terms,  it  may  be  said 
that  every  additional  year  of  life  after  fifty  increases  the  prob- 
ability that  a  neuralgia,  should  such  arise,  will  be  severe  and 
rebellious  to  treatment ;  and  in  the  very  aged  the  cure  of  such 
affections  is  probably  impossible. 

8.  This  seems  the  proper  place  to  introduce  such  facts  as  have 
been  observed,  and  they  are  very  few,  that  directly  illustrate 
the  material  changes  occurring  in  neuralgia. 

Very  much  the  most  important  of  these  facts  is  the  history  of 
a  remarkable  case  recorded  by  Romberg.  ["Diseases  of  Ner- 
vous System,"  Syd.  Soc.  Trans.,  vol,  i.]  The  patient,  a  man 
sixty-five  years  old  at  the  time  of  his  death,  had  suflPered  for 
several  years  from  the  most  violent  and  intractable  epilepti- 
form trigeminal  neuralgia,  complicated  with  interesting  trophic 
changes  of  the  tissues.  Post-mortem  examination  showed  that 
the  pressure  of  an  internal  carotid  aneurism  had  almost 
destroyed  the  Gasserian  ganglion  of  the  painful  nerve,  that  the 
trunk  and  posterior  root  of  the  nerve  were  in  a  state  of 
advanced  atrophic  softening,  and  the  atrophic  process  had 
extended  in  less  degree  to  the  nerve  of  the  opposite  side.  Now, 
the  value  of  this  case  is  by  no  means  restricted  to  the  fact  that 
it  records  the  existence  of  a  particular  anatomical  change  m 
one  example  of  neuralgia.  Its  most  striking  teaching  is  the 
fact  that  the  acutest  agonies  of  neuralgia  can  be  felt  in  a  nerve, 
the  central  end  of  which  is  reduced  tosuch  a  pitch  of  degener- 
ation that  conduction  between  centre  and  periphery  must  very 
shortly  have  entirely  ceased  had  the  patient  lived.  And  hardly 
less  important  is  its  illustration  of  the  fact  that  permanent 
injury  to  the  ganglion  of  the  posterior  root  of  a  spinal  nerve 
impairs  the  vitality  of  the  posterior  root  itself — a  fact  which 
has  been  independently  made  out  by  the  physiological 
reseai'ches  of  Bernard  and  of  Augustus  Waller. 

On  the  other  hand,  if  we  examine  the  tolerably  numerous 
histories  of  cases  in  which  the  painful  nerves  have  been  exam- 
ined at  the  apparent  site  of  pain,  we  discover  nothing  to  lead 


122  PATHOLOGY. A^'D  ETIOLOGY  OF  NEURALGIA. 

US  to  connect  neuralgia  definitely  Tvitli  any  one  sort  of  change. 
Assuredly,  for  example,  local  neuritis  is  by  no  means  univer- 
sally, it  is  probably  even  not  commonly,  present  in  the  early 
stages  of  neuralgia;  it  has  also  been  repeatedly  detected  in 
nerves  that  had  been  vholly  free  from  neuralgia :  and,  on  the 
other  hand,  it  has  been  entirely  absent  in  nerves  that  have 
been  the  seat  of  the  severest  pains.  Moreover,  many  facts 
Tvhich  have  been  put  down  Tvithout  reflection,  as  showing  a 
local  peripheral  cause  for  neuralgia,  are  at  least  open  to 
another  and,  as  I  believe,  truer  explanation;  as  (e.  g.)  in 
the  following  remarks  of  Eulenburg  on  mechanical  ini- 
tations  of  nerves  as  causes  of  neuralgia:  "Diseases  of 
bones  are  extraordinarily  frequently  the  cause  of  neuralgias 
in  consequence  of  compression  or  secondary  disease,  which 
affects  the  branches  of  nerves  passing  through  canals, 
foramina,  fissures,  or  over  processes  of  bone.  The  ap- 
jiearances  which  the  opportunities  of  resections  of  the 
trigeminus  for  facial  neuralgia  have  permitted  to  be  discovered, 
have  given  us  valuable  information  in  that  direction.  Flat- 
tening and  atrophy  of  nerves  from  x^eriostitis,  or  from  concen- 
tric hypertrophy  in  narrovred  bony  canals,  have  frequently 
been  discovered.  Tlie  neurilemma  at  the  narrowed  parts  was 
often  seen  reddened,  ecchymosed,  mfiltrated  with  seriun,  or 
surrounded  with  fibrous  exudation:  occasionally  inflammation 
had  been  followed  by  partial  thickening  of  the  neurilemma 
(fibi'ous  knots)  and  turbidity  (Trubungenj  of  the  nervous  cord 
at  the  corresponding  spot.  Similar  apioearances  have  beer 
noted  in  other  neuralgias  fneuralgia-braehialis,  sciatica,).'' 
For  my  own  part,  I  believe  that  the  above  description  repre- 
sents tbe  facts  from  an  erroneous  point  of  view.  True  neural- 
gia, if  by  that  we  understand  a  pain  of  intermittent  character 
limited  to  one  or  more  nerves,  is  in  my  experience  an 
extremely  uncommon  result  of  periosteal  disease,  or  of  mfiam- 
mation  of  the  linings  of  bony  canals;  but  in  a  great  number 
of  instances  such  diseases  appear  to  be  set  up  as  the  secondary 
consequence  of  the  neuralgic  ]Drocess  (whatever  the  essential 
nature  of  that  may  be)  gomg  on  in  sensory  nerves  which  sup- 
ply the  parts  when  these  inflammations  appear.  And  it  must 
be  remembered  that  the  specimens  obtained  by  resection  of 
nerves  are  comparatively  few  in  number,  and  are  taken  univer- 
sally from  old-standing  and  desperate  cases  of  disease;  in 
shoi't,  from  cases  which  are  just  in  those  advanced  stages  of 
neuralgia  in  which,  as  has  already  been  amply  shown,  these 
secondary  inflammations  are  almost  always  present.  On  the 
other  hand.  I  have  myself  had  one  opportunity  of  examining 
the  local  condition  of  an  intercostal  nerve,  which  during  life, 
and  quite  up  to  death,  had  been  tbe  site  of  the  most  pro- 
nounced neuralgia,  vrhich,  however,  had  only  existed  for  a 
few  days.     The  patieut,  a  young  maii,  aged  twenty-j;even,  was 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  123 

pr-obably  insane,  and  had  attempted  suicide.  Not  a  trace  of 
inflammation,  either  in  the  nerve  itself  or  in  any  of  the  tis- 
sues to  which  it  was  distributed,  could  be  detected.  (This  was 
a  case  in  which  I  gi'eatly  regi'etted  the  impossibility  of  getting 
a  family  liistory  that  was  at  all  reliable.)  The  spinal  cord, 
unfortunately,  could  not  be  examined.  And  I  strongly  believe, 
from  the  marked  absence  of  tenderness  on  pressure  which  is 
almost  universally  observed  in  ordinary  cases  of  neuralgia  at 
an  early  stage,  that  ])ruTaarj  inflammation  of  neurilemma, 
periostem,  etc.,  as  a  cause  of  neuralgia,  is  altogether  excep- 
tional; so  much  so,  that  we  are  entitled  to  believe  it  can  never 
be  more  than  a  concurrent,  and  then  not  the  most  important, 
cause. 

It  is  necessary  here  to  inquire,  more  particularly  than  we 
have  yet  done,  into  the  nature  of  the  "  painful  points"  first 
signalized  by  Valleix  as  a  distinctive  symptom  of  neuralgia. 
Very  gi-eat  differences  of  opinion  have  prevailed  among  sub- 
sequent writers,  both  as  to  the  frequency  and  the  significance 
of  these  points.  It  may  be  said,  however,  to  be  now  quite 
settled  that  the  presence  of  definite  points,  pamful  on  pres- 
sure, and  also  corresponding  to  the  foci  of  severest  sponta- 
neous pain,  is  far  from  universal  in  neuralgia.  Upon  this 
point  there  is  probably  no  reason  to  doubt  the  coi'rectness  of 
Eulenburg's  observations  made  in  the  surgical  clinic  of  Grreif- 
swald  and  the  polyclinic  of  the  University  of  Berlin;  he  says 
that  he  discovered  the  existence  of  tender  points  in  "  Valleix's 
sense,"  in  rather  more  than  half  the  cases  of  superficial  neu- 
ralgia, but  in  the  rest  he  could  not  by  any  means  discover 
them.  In  many  other  cases,  however,  he  found  more  indefi- 
nite points  of  tenderness,  not  accurately  corresponding  to 
nerve-branches,  but  aff^ecting  individual  portions  of  skin, 
bone,  or  joints ;  the  relation  of  these  to  the  neuralgic  symp- 
toms was  difficult  of  explanation.  Eulenburg  lays  down  the 
principle  that  "  hypersesthesia  "  may  depend  on  three  sorts  of 
eauses — (1)  On  local  disease  of  the  peripheral  ends  of  nerves; 
(2)  on  alterations  of  the  psychical  centres ;  and  (3)  on  mor- 
bidly exaggerated  conduction  in  the  nerve-trunks  themselves ; 
and  it  is  to  this  third  source  that  he  attributes  many  of  the 
phenomena  of  the  neuralgic  painful  points,  and  especially 
their  multiplicity,  in  many  cases.  The  locus  in  quo  of  the 
mischief  which  sets  up  this  exaggerated  conduction  of  sensory 
impression  is,  upon  this  theory,  between  the  psychical  centre 
and  the  main  point  of  branching  of  the  nerves ;  hence  a  large 
number  of  peripheral  nerve-term  mi  might  be  pi'actically  sen- 
sitive to  touch,  because  the  mischief,  though  localized"  in  a 
comparatively  small  spot,  might  easily  affect  many  bundles  of 
fibres,  which  diverge  Avidely  from  each  other  in  their  course. 
It  will  be  seen  presently  with  what  liTnits  and  for  what  reasons 
we  believe  this  to  be  a  true  theory .     But  to  return  to  the  ques- 


124  PATHOLOGY  AIsD  ETIOLOGY  OF  NEURALGIA. 

tion  of  painful  points  in  Valleix  s  sense,  we  must  state  one  or 
two  facts  which  seem  cei'taiu  from  our  own  experience,  but 
have  not  been  adequately  recognized,  we  believe,  by  others. 
The  first  is,  that  localized  tender  spots,  accurate  jjressure  on 
which  will  set  up  or  aggravate  the  neuralgic  pain,  ai*e  not 
early  phenomena,  save  in  neuralgias  of  exceptional  sevei'ity 
of  onset ;  but  that  a  certain  persistence  and  severity  of  neuj'al- 
gia  are  always  followed  by  the  formation  of  one  or  more  true 
points  douloureux.  The  second  fact  relates  to  the  clinical  his- 
tory of  migi'aine .  Roughly  speaking,  it  is  true,  as  Eulenburg 
states,  that,  in  pure  migraine,  painful  points  in  Vallebi's  sense 
are  not  to  be  found;  in  place  of  them  we  observe,  after  the 
paroxysms  have  passed  away,  a  more  generalized  soreness  of 
considerable  tracts  of  the  scalp,  forehead,  etc. ,  or  diffuse  ten- 
derness of  the  eyeball.  But  I  must  here  again  refer  to  the 
fact,  fii'st  observed  in  my  own  case,  and  afterwai'd  verified  in 
many  others,  that  migraine  may  be  only  the  youthful  prelude 
to  a  regular  trigeminal  neuralgia  attended  with  the  formation 
of  chai'acteristic  localized  painful  points  at  a  later  period. 
Ajid  the  thu'd  fact  that  must  be  specially  mentioned  is  that 
the  true  Valleix's  i)oint,  when  it  has  become  established  for 
some  time,  is  not  a  mere  spot  of  sensitive  nerve,  but  is  the 
scene  of  troijhic  changes,  involving  hj-pera3mia  and  thick- 
ening of  'pavis  surrounding  the  nerve.  To  give  one  example, 
it  is  quite  a  frequent  thing  to  find  a  patch  of  tender  and  sensi- 
bly thickened  periosteum  of  irregular  shape,  but  equal  some- 
times to  a  square  inch  in  size,  over  the  frontal  bone  at  and 
immediately  above  the  mner  end  of  the  eyebrow,  in  cases 
where  supra-orbital  neuralgia  has  recurred  frequently  during 
some  years,  although  no  such  thing  was  present  when  the  neu- 
ralgia first  commenced.  In  my  own  case,  the  bone  has  become 
sensibly  thickened  at  that  pomt. 

Tlie  general  result  of  such  post-mortem  and  clinical  infor- 
mation as  can  be  had  seems  clearly  to  be  that  positive  anatomi- 
cal changes,  either  of  nerve-terminals  or  superficial  nerve- 
branches,  are  but  casual  and  infrequent  factors  in  the  first 
production  of  neuralgia,  and,  in  particular,  it  would  seem 
that  infiammation  of  a  nerve  itself  by  no  means  necessarily 
produces  neuralgic  pain,  but  (far  moi'e  commonly)  simple 
paralgesia  or  anEesthesia  of  the  parts  external  (peripheral)  to 
the  lesion.  The  one  marked  exception  to  this  general  proposi- 
tion is  to  be  found  in  the  case  of  the  severQ  and  peculiar  inju- 
ries inflicted  on  the  trunks  of  nerves  by  gunshot-wounds 
which,  as  we  have  seen  (from  the  American  experiences),  can 
produce  some  of  the  most  dreadful  forms  of  neuralgia.  But 
the  nature  of  the  injury  here  inflicted  is,  it  must  be  remem- 
bered, quite  different  from  any  thmg  which  either  disease  or 
accident  in  civil  life  would  produce,  save  in  the  most  excep- 
tional instances.    For  the  chief  material  element  in  the  pro- 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  125 

duction  of  the  neuralgias  of  oi'dinary  life  we  are  really  driven, 
by  exclusion,  to  the  condition  of  "the  posterior  roots  of  special 
nerves,  in  some  cases,  perhaps,  to  the  (spinal)  ganglia  on 
which  the  nutrition  of  these  roots  probably  is  considerably 
dependent. 

With  the  field  thus  narrowed  for  us,  it  is  surely  legitimate, 
in  the  necessary  scarcity  of  anatomical  records  referring 
directly  to  the  state  of  the  nerve-roots  in  ordinary  neuralgia, 
to  place  great  weight  on  the  facts  of  a  disease  like  locomotor 
ataxy,  in  which  the  main  anatomical  change  is  a  progressive 
atrophy  of  the  posterior  columns  which  usually  falls  with 
peculiar  severitv  on  the  posterior  nerve-roots,  or  on  the  parts 
of  the  gray  matter  immediately  adjoining  these,  and  in  wliich 
neuralgia  may  be  said,  for  practical  purposes,  to  be  a  constant 
and  most  characteristic  phenomenon.  If  any  one  desires  to 
see  how  strikingly  the  connection  of  the  neuralgic  x)henomena 
with  the  anatomical-change  comes  out,  I  rocommend  him  to 
study  Dr.  Lockhart  Clarke's  papers  on  locomotor  ataxy  [vide 
•'  St.  George's  Hospital  Reports,i'  1866;  Lancet,  June,  10  1865; 
"Med.-Chir.  Soc.  Transactions,"  1869),  or  the  excellently 
repoi'ted  case  by  Nothnagel  (jBe^-Zm  Klin.  Wocliensch.,1^%^). 
It  is  really  not  too  much  to  say  that  the  only  important  differ- 
ance  between  the,  clinical  as]3ect  of  the  pains  of  locomotor 
ataxy  and  those  of  ordinary  neuralgia  is  simply  such  as  depends 
on  the  fact  that  the  anatomical  change  in  the  former  case  is 
bi-lateral,  and  usually  affects  the  roots  of  several,  sometimes  of 
a  great  many  pairs  of  nerves.  I  infer,  from  a  convereation 
with  Dr.  Clarke,  that  he  fully  recognizes  the  force  of  the  ana- 
logy, and  the  greai  strength  of  the  presumption  which  it  sets 
up  in  favor  of  an  atrophic  change  of  the  posterior  roots  in 
neuralgia. 

It  may,  of  course  be  urged,  against  the  view  that  neuralgia 
depends  on  any  change  analogous  to  those  wliich  occur  in 
ataxy,  that  quantities  of  cases  of  the  foi'mer  recover  speedily, 
and  must  be  supposed  to  be  either  independentof  material  change 
altogether  or,  at  any  rate,  to  have  involved  only  very  trivial 
anatomical  changes,  not  formidable  diseases,  like  atrophy  of 
nerve-centres.  I  find  it  impossible  to  admit  that  this  argu- 
ment has  the  slightest  force.  Are  we  to  suppose  that  the  pos- 
terior nerve- roots  alone,  of  all  tissues  and  organs  of  the  body, 
are  incapable  of  minute  and  partial  changes  in  the  direction  of 
molecular  death  which  may  be  perfectly  recovered  from  in 
wfeeks,  months,  or  even  days  ?  I,  for  one,  cannot  doubt,  that 
such  changes  are  of  frequent  occurrence,  in  all  parts  of  the 
central  nervous  system,  when  I  can  consider  the  absolute 
dependence  of  these  portions  of  the  organism  upon  a  perfect 
blood-supply,  and  the  immense  number  of  possible  causes  of 
temporary  interference  with  that  source  of  nutrition.  And  I 
can  see  no  probable  difference,  except  in  degree  and  persistence 


126  PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA. 

between  the  effects  on  sensation  which  would  be  produced  by 

such  a  change  of  the  posterior  roots  as  this,  and  tliat  which 
would  result  from  the  more  serious  and  fatally  continuous 
change  which  is  involved  in  locomotor  ataxy. 

9,  We  come  now  to  a  most  important  but  most  complex  and 
difficult  portion  of  the  argument  respecting  the  locus  in  quo  of 
the  essential  pathological  process  (if  such  there  be)  in  neui'algia ; 
viz.,  as  to  the  paths  and  the  character  of  the  so-called  "  reflex" 
influences  which  intervene  in  the  causation,  both  of  neuralgia 
itself,  and  also  of  the  numerous  complications  with  which  we 
have  seen  that  neuralgia  is  liable  to  be  attended.  The  chnical 
facts  which  confront  us  here,  and  demand  explanation,  are 
the  following :  (1)  Irritation  so  called,  of  sensory  fibres  may 
apparently  evoke  pains  attributed  to  the  site  of  the  irritation, 
or  to  the  parts  on  the  peripheral  side  which  are  supplied  by  the 
same  sensory  nerves  (3)  Peripheral  irritation  of  a  particular 
sensory  nerve  may  evoke  neuralgic  pains  in  nerves  connected 
with  that  irritated  only  through  the  spinal  centre.  (3)  Neu- 
ralgia in  a  sensory  nerve  may  (and  almost  always  does,  to 
some  extent)  produce  secondary  vaso-motor  paralyses :  these 
paralyses  may  affect  fibres  which  run  in  the  same  branch  of 
the  nerve  as  that  which  is  painful,  or  fibres  that  run  in  another 
branch  of  the  same  nerve,  or  fibres  that  run  with  another 
sensory  nerve,  or  the  ganglionic  chaui  of  the  sympathetic 
itself.  (4)  In  like  secondary  manner,  neuralgia  may  produce  vaso- 
motor spasms  in  any  of  the  directions  just  specified ;  this  is  usu- 
ally a  short-lived  phenomenon,  giving  place  quickly  to  paralysis ; 
but  Du  Bois  Reymond's  often-quoted  analysis*  of  his  own  suf- 
ferings from  migraine  seems  to  show  that  spasm-producing  irri- 
tation of  the  trunk  of  the  sympathetic  may  last  during  some 
hours.  (5)  Neuralgia  in  a  sensory  nerve  may  increase,  alter, 
or  (more  rarely)  suspend  the  seci^etions  of  glands  supplied 
by  fibres  bound  up  either  in  the  sanae  branch,  or  in  another 
branch  of  the  same  nerve,  or  in  a  different  nerve  with  which 
it  is  connected  only  through  the  centre  or  (possibly)  only 
through  a  plexus.  (6)  Neuralgia  in  a  sensory  nerve  can  pro- 
duce paralysis  of  muscles  supplied  by  motor  fibres  bound  up 
with  the  painful  branch,  or  with  another  branch  of  the  same 
nerve,  or  in  muscles  supplied  by  a  totally  distinct  nerve  con- 
nected only  through  the  centime.  (7)  It  may  produce  convul- 
sion and  spasms  of  muscles,  in  all  the  above  directions; 
this  usually  alternates  with  great  weakness,  or  actual  paralysis 
of  the  same  muscles.  (8)  It  may  produce  partial  or  complete 
loss  of  common  or  special  sensation  in  nerve-fibres  that  run 
either  with  ths  same  branch,  or  with  another  branch  of  the 
same  nerve.  (9)  It  may  produce  trophic  changes,  either  in 
the  direction  of  simple  atrophy  or  of  sub-acute  inflammation 

*  Journal  de  la  Physiologie,  v. 


PATHOLOGY  AND  ETIOLOGY    OF  NEURALGIA,  137 

wifh  proliferation  of  lowly- vitalized  tissue  (e.  g^ ,  connective")  in 
the  parts  with  which  are  supplied  with  sensation  by  the  pain- 
ful branches  or  by  other  branches  of  the  same  nerve. 

It  is  necessary  to  go  over  again  the  proof  of  these  facts ;  they 
are  given  pr-etty  copiously  in  the  chapter  on  Complications ; 
and  could  have  been  made  much  more  numerous.  But  the 
point  to  which  I  desire  to  compel  the  reader's  attention  is  the 
impossibility  as  it  seems  of  me,  of  accounting  for  the  vax-i- 
eity  and  complexity  of  these  phenomena,  except  by  the  sup- 
position that  there  is  in  every  case  of  neuralgia  a  central 
change,  which  is  the  one  most  important  factor  in  the  pro- 
ducing both  of  the  pain  and  of  the  secondary  phenomena. 
For  the  result  of  my  experience  is  that  neuralgia,  unless  very 
slight  and  brief,  is  never  unattended  by  these  complications 
and  in  the  great  majority  of  cases  involves  several  different 
secondary  alterations  of  function  which  must  (so  to  speak) 
radiate  from  the  central  end  of  the  sensory  nerve,  and  from 
no  other  place  whatever.  And  it  must  be  remembered  that  the 
most  elaborate  ''''  syniptome-complexe'''  (is  found  equally  in 
cases  where  no  suggestion  of  any  j)eripheral  origin  of  the  pain 
can  be  made,  and  in  cases  where,  at  first  sight,  one  might 
fancy  there  was  a  very  obvious  peripheral  cause  for  pain.  I  am 
quite  willing  to  admit,  with  Eulenburg  and  others,  that  the 
evidence,  powerful  and  varied  though  it  be  of  the  relations  of 
neuralgia  to  hereditary  neuroses,  to  alcoholic  and  senile  degen- 
eration, etc.,  only  raises  a  strong  probability  that  some  part 
of  the  central  nervous  system  is  the  locus  in  quo  of  the  essen- 
tial morbid  processes  in  the  majority  of  neuralgias.  But  the 
case  stands  far  otherwise  now  that  we  are  able  to  show,  not 
merely  that  the  majority  of  neuralgic  patients  suffer  from  such 
influences  as  those  above  mentioned,  but  that  every  variety  of 
neuralgia  is  liable  to  be  complicated  with  secondary  affections 
of  the  most  divergent  nerves,  the  only  common  meeting-place 
of  which  is  in  the  spinal  centre  of  the  painful  nerve ;  and  when 
we  find  moreover,  that  many  of  these  secondary  affections  can 
equally  be  produced  by  undoubted  atrophic  changes  (as  in 
ataxy  of  those  same  posterior  roots. 

At  this  point  we  must  introduce  a  remark  relative  to  the  true 
nature  of  so-called  "  reflex  "  effects.  The  word  is  constantly 
used,  and  is  also  much  abused,  as  Eulenburg  remarks.  We  all 
understand,  of  course,  what  is  intended  by  the  commonest  use 
of  the  word  :  the  case  of  sneezing  produced  by  the  irritation 
of  snuff  applied  to  the  peripheral  branches  of  the  fifth  nerve 
in  the  nose  is  a  stock  example.  But  another  application  of  the 
phrase,  of  much  more  questionable  propriety,  is  that  where  it 
is  employed  to  designate  functional  nervous  actions,  which 
merely  arise  simultaneously  with  or  subsequently  to  sensory 
phenomena  as  to  which  there  is  no  proof  whatever  that  they 
were  produced  by  peripheral  irritation.     This  particular  inac- 


138  PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.. 

curacy  of  customary  speech  has  probably  contributed  largely 
to  the  inveteracy  with  which  writei^s  on  nervous  disease  have 
insisted  on  assuming-  a  peripheral  origin  in  every  case  for  neu- 
ralgia itself.  In  the  case  of  sciatica,  for  example,  complicated, 
secondarily,  with  paralysis  of  the  flexors  of  the  limb,  it  seemed 
easy  and  scientific  to  speak  both  of  the  neuralgia  and  the  par- 
alysis as  ' '  reflex  "  effects  of  a  local  peripheral  mischief — 
gouty,  rheumatic,  or  the  like ;  and  it  appears  to  have  been  per- 
fectly forgotten  by  many  that  the  whole  phenomena  might  be 
explained  by  an  original  morbid  action  in  the  sensory  root  of 
the  nerve,  extending  subsequently  to  the  motor  root,  without 
any  intervention  of  peripheral  irritation  whatever,  or  under 
the  influence  only  of  the  ordinary  peripheral  impressions, 
which,  in  health,  evoke  no  jjainful  nor  paralytic  symptoms. 
It  is  by  this  kind  of  extension  of  a  central  morbific  process, 
leading  to  radiation  of  the  perturbing  influence  centrifugally 
along  divers  nervous  paths,  that  I  believe  we  must  explain  the 
facts  observed  in  complicated  cases. 

Take,  for  example,  the  followmg  case,  which,  in  its  history 
of  twenty-three  years,  presents  a  fair  example  of  a  type  of 
trigeminal  neuralgia  which  I  believe  to  be  the  rule  rather  than 
the  exception,  though  the  trophic  changes  were  somewhat  unu- 
sually varied  and  interesting.  The  following  would  be  the 
pathological  order  of  events,  according  to  the  radiation  theory : 
First  or  true  migrainous  stage;  failure  of  nutrition  of  a  por- 
tion of  the  sensory  root  of  the  right  fifth  nerve  within 
medulla  oblongata,  lesser  degree  of  the  same  condition  in  the 
adjoining  and  closely-connected  vagus  root  (hence  supra-orbi- 
tal pain,  local  anaesthesia  and  vomiting) ;  extension  of  the 
morbid  process  to  the  motor  root  (hence  vaso  motor  paralysis 
and  secretory  and  trophic  changes  in  the  conea,  superciliary 
periosteum,  etc).  Second  period :  recovery,  to  a  large  extent, 
of  the  nutrition  of  the  posterior  root  of  the  trigeminus,  com- 
plete recovery  of  the  root  of  the  vagus  (hence  alteration  of 
the  type  of  recurrence  of  the  pains,  which  now  occur  at 
increasingly  long  intervals,  and  needed  special  provocation, 
e.  g. ,  excessive  fatigue,  to  bring  them  on ;  hence,  also,  disap- 
pearance of  the  stomach  symptoms) ;  continuance  of  the  affec- 
tion of  the  motor  portion  of  the  nerve  (hence,  continuance  of 
the  tendency  to  trophic,  secretory,  and  vaso-motor  changes; 
develpoment  of  the  true  points  douloureux  during  and  after 
the  paroxysms,  instead  of  the  diffused  tenderness  following 
the  old  attacks  of  migraine.  Third  stage :  neuralgic  attacks 
become  rare  and  comparatively  unimportant;  tendency  to 
trophic  changes  greatly  lessened;  local  anaesthesia  persists. 
Presumption,  that  the  nutrition  of  the  nerve-centre  has  nearly 
recovered  itself,  but  that  that  centre  is  still  the  locus  minimoe. 
resistentice  of  the  central  nervous  system,  liable  to  suffer  from 
any  cause  of  general  nervous  depression. 


PATHOLOGY  AND  ETIOLOGY  OP  NEURALGIA.  129 

Now,  in  interpreting  the  above  phenomena,  as  I  do,  upon 
the  theory  of  one  essentially  uniform  nutritive  change  affect- 
ing the  fifth  nerve  withni  the  medulla  oblongata,  I  sball  be 
met  with  the  following  objections :  First,  there  is  the  common 
and  superficial  difficulty  that  pain  and  pai^alysis  of  sensation 
must  be  opposite  states,  and  that  it  is  impossible  to  refer  them 
both  to  one  and  the  same  pathological  process.  I  have  already 
in  many  places  given  instances  how  constantly  pain  and  sen- 
sory paralysis  interchange  in  a  manner  which  is  totally  incom- 
prehensible except  upon  the  supposition  that  their  physiologi- 
cal basis  is  essentially  the  same ;  but  the  most  satisfactory  evi- 
dence, perhaps,  that  could  possibly  be  produced  on  this  point 
is  to  be  found  in  the  perusal  of  a  group  of  cases  observed  by 
Hippel,*  and  entitled  by  him  "  Anaesthesia  of  the  Trigemi- 
inus,"  the  loss  of  sensation  being  the  most  remarkable  fea- 
ture. The  cases  are  so  deeply  interesting  that  I  would 
gladly  transfer  them  bodily  to  these  pages,  but  must  abstain 
from  want  of  space.  Suffice  it  to  say  here,  that,  in  the  ffi'st 
place,  the  anaesthesia  was  accompanied,  in  every  one  of  these 
cases,  by  a  most  distinct  and  typical  neuralgia;  and,  secondly, 
that  trophic  changes  occurred  which  most  interestingly  (though 
not  with  absolute  completeness)  reproduced  the  phenomena 
observed  after  complete  section  of  the  trigeminus  at  the  Gras- 
serian  ganglion. 

The  second  objection  sure  to  be  raised  to  the  theory  of  a  sim- 
ple spreading  of  a  nutritive  central  change,  as  the  cause  of  all 
the  phenomena  in  such  a  case  as  the  above,  is  this:  It  will  be 
asked  how  the  process  extended  itself  to  the  motor  root,  which, 
in  the  case  of  the  fifth  nerve,  is  removed  by  a  somewhat  for- 
midable anatomical  distance  from  the  sensory  root.  I  am,  of 
course,  well  aware  of  the  latter  fact,  and  it  is  an  additional 
reason  for  selecting  neuralgia  of  the  fifth,  as  an  extra  difficult 
test  of  the  value  of  my  theory.  A  few  words  must  be  pre- 
mised, reminding  the  reader  of  the.  physiological  anatomy  of 
the  nerve. 

The  trigeminus  is  in  all  its  characters  a  spinal  nerve ;  but  it 
has  sundry  peculiarities  both  of  structure  and  of  connections 
with  other  nerves.  Its  postei'ior  or  sensory  root  is  enormous, 
and,  as  Schroder  van  der  Kolk  showed,  takes  a  dii'ection  from 
behind  downward  and  forward,  which  is  intended  to  facilitate 
its  numerous  and  important  connections  with  the  nuclei  of 
other  nerves:  of  these  the  most  notable  are  its  connections 
with  the  vagus,  facial,  glosso-pharyngeal,  and  hypo- glossal 
nuclei.  The  motor  root,  much  smaller  than  the  sensory,  was 
shown  by  Lockhart  Clarke  to  be  traceable  as  low  as  the  inferior 

*  "  Erna'irungssloningeu  der  Augeii  bei  Anaestliesie  dcs  Trigem- 
inus."   Mitgclheilt  von  Dr.  v.  Hippel  in  Konigsberg  in  Preussen. 
Arcliiv  f.  Oplithalm.     Band,  xiii 
9 


130  PATHOLOGY  AJTD   ETIOLOGY  OF  NEURALGIA. 

border  of  the  olivary  body,  as  a  column  of  cells  wliich  occu- 
pies a  situation  corresponding  to  that  of  the  anterior  course  of 
the  spinal  gray  matter. 

As  this  column  passes  onward  in  the  medulla  oblongata,  on 
a  level  with  the  glosso-pharyngeal  nerve,  it  forms  a  group  of 
cells  of  large  size.  Besides  numerous  other  connections  which 
it  forms,  Clarke  describes  the  motor  root  as  sending  processes 
forward,  like  tapering  brushes  or  tails  of  fibres,  in  connection 
with  more  scattered  cells  lying  in  their  course,  which  may  be 
frequently  seen  to  communicate  with  the  transverse  bundles 
which  traverse  the  "  gray  tubercle  "  and  the  sensory  roots  of 
the  fifth  contained  therein.  In  this  way  the  sensory  root, 
though  seemingly  much  separated  from,  is  really  in  very 
direct  connection  with,  the  motor  root. 

Now,  proofs,  which  must  be  considered  almost  positive,  have 
recently  been  adduced  to  show  that  the  nerve-fibres  concerned 
in  those  peculiar  alterations  in  the  tissues  supplied  by  the 
ophthlamic  division  of  the  fifth,  which  occur  in  section  of  the 
trigeminus,  come  entirely  from  the  motor  root  of  the  fifth,  and 
form  a  very  small  band  in  the  inner  or  medial  margin  of  the 
ophthalmic  trunk.  The  observation  of  Meissner*  goes  to  show 
that  it  is  possible  (by  good  luck)  to  divide  the  trunk  in  such  a 
pai"tial  manner  as  to  cut  only  the  inner  fibres,  and  thereby 
produce  the  trophic  eye-changes  without  any  ansesthesia,  or 
only  the  sensory  fibres,  and.  thereby  induce  anesthesia  without 
any  trophic  changes ;  and  it  must  be  owned  that  this  really 
affords  the  only  reasonable  explanation  of  the  discrepancy 
between  the  expei^imental  results  obtained  by  Magendie  and 
Berna^rd ;  and  also  the  facts  of  such  cases  as  those  related  by 
Mr.  Hutchinson,  f  who  in  two  instances  found  that  a  com- 
pletely anaesthetic  eye  recovered  perfectly  well  from  the  wound 
made  in  a  surgical  operation.  The  nature  of  the  nervous  influ- 
ence (whether  ordinary  vaso-motor  only,  or  a  special  tropliic 
function)  has  been  greatly  disputed.  Dr.  Wegner,t  from 
observing  the  remarkable  group  of  glaucomatous  cases  under 
Horner  (of  which  one  has  been  related),  made  experiments, 
from  which  he  concluded  that  the  augmentation  of  intra- 
ocular pressure  in  glaucoma  was  a  phenomenon  depend- 
ent upon  the    sympathetic,    which  was    irritated  by  reflec- 

*Zeitsch.  f.  rat.  Med.,  1867.  There,  is  con-oborative  evidence, 
from  independent  sources,  of  tlie  tnitli  of  Meissner's  views.  His  own 
observation  only  proved  lialf  the  case;  but  he  quotes  an  observation 
of  Butlman's  in  which  the  exact  converse  of  liis  own  experience  hap- 
pened, tlie  external  fibres  beiui;-  affected  without  the  inner  baud,  and 
ausesUiesia  witliout  tropliic  changes  being  the  result,  Moreover, 
Schiff  (Gaz.  iiebdom.,  1867)  obtained  experimental  results  (in  operat- 
ing on  cats  and  rabbits)  which  coincide  with  Meissner's, 

I  London  Hospital  Reports,  vol.  iii.,  p.  305. 

I  Weguer,  loc.  cit. 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  131 

tion  from  the  trigeminus.  But  the  researches  of  Hippel  and 
Grunhagen,  especially  their  latest,*  give  a  different  explana- 
tion, excluding  the  sympathetic ;  they  found  that  irritation  of 
tlie  medulla  oblongata,  in  the  neighborhood  of  the  trigeminus 
root,  produced  a  lasting  and  very  pronounced  augmentation 
of  intra-ocular  blood-pressure,  an  effect  which,  they  remark, 
could  not  dei^end  on  irritation  of  the  vaso-mtttor  centre,  since 
that  must  produce  contraction  of  the  vessels  and  lowering  of 
the  blood-pressure.  They  conclude  that  "  the  trigeminus  con- 
tains specific  fibres  which  possess  the  property  of  actively  dilat- 
ing the  blood-vessels  of  the  eye ;"  and  in  reference  to  the  secre- 
tion of  the  fluid  humors  of  the  eye,  they  conclude  also  that 
"the  trigeminus  also  plays  the  part  of  an  (active)  nerve  of 
secretion." 

Of  these  oonflicting  opinions  I  can  have  no  difficulty  in  at 
any  rate  rejecting  that  of  Wegner ;  for  the  clinical  phenomena 
of  the  complications  attending  trigeminal  neuralgia,  such  as 
they  are  described  in  my  last  chapter  (and  could  have  been 
described  at  much  greater  length),  seem  to  me  utterly  to 
exclude  vaso-motor  spasm  except  as  a  temporary  phenomenon 
at  the  commencement  of  the  attacks  of  acute  pain.  Vaso- 
motor palsy  undoubtedly  is  very  often  present,  in  fact  every 
attack  of  neuralgia  of  a  certain  severity  is  thus  complicated; 
and  there  is  no  reason  to  doubt  that  this  paralysis  could  be 
caused  by  lesions  within  the  medulla.  Are  we,  then,  to  admit 
functions  of  active  dilatation  of  vessels,  and  active  impulse  to 
secretion  in  certain  fibres  of  the  fifth  ?  It  is  necessary  at  any 
rate  to  clear  the  ground  in  one  respect :  it  must  not  be  supposed 
that  I  for  a  moment  entertain  the  idea  that  there  can  be  direct 
active  dilatation,  i.  e. ,  that  there  can  be  any  system  of  muscu- 
lar fibres  (and  nerve-fibres  stimulating  them)  whose  office  is  to 
open  the  calibre  of  the  vessels ;  the  idea  is  wildly  improbable — 
in  fact  almost  inconceivable  by  any  one  who  reflects  on  the 
necessary  machinery — and  there  is  not  a  single  observed 
anatomical  fact  to  give  it  support.  If,  then,  I  speak  of  the 
possibility  of  "  active  "  dilatation,  it  must  be  understood  that  I 
refer  toa  theory  of  "inhibition,"  which  supposes  certain  fibres 
to  be  gifted  with  the  power  of  paralyzing  or  inhibiting  the 
vaso-motor  nerves.  It  is  my  duty  to  speak  with  all  reasonable 
reserve  on  that  most  difficult  qucestio  vexata,  the  existence  of 
special  inhibiting  systems  of  nerves,  and  the  extent  to  which  a 
double  series  of  opposed  nervous  actions  is  generalized  in  the 
body ;  but  it  is  impossible  to  avoid  the  subject  altogether,  and 
I  offer  the  the  following  remarks,  with  deference,  to  our  pro- 
fessional physiologists.  The  strongest  instances  of  the  appar-, 
ent  inhibiting  action  are  probably  afforded  by  the  nervi 
erigentes,  as  shown  by  Loven,  the  cardiac  depressor,  by  Lud- 

*  Arcbiv  f.  Ophthalra.,  xv.,  1. 


332  PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA. 

■wig  and  Cyon,  and  the  splanchnics  (upon  the  intestine),  by 
Pfluger.  But  there  is  not  a  single  one  of  these  examples  that 
has  not  been  challenged  by  experimenters  of  repute.  Thus  the 
theory  of  the  distinctive  restraint-action  of  the  splanchnics 
upon  the  intestine,  and  of  the  vagus  upon  the  heart,  has  been 
especially  controverted  by  Piotrowski,  who,  indeed,  rejects  the 
whole  theory  of  special  inhibitory  nerves.  *  And,  from  another 
point  of  view,  Mr.  Lister  long  ago  attacked  the  views  of 
Pfluger,  maintaining  that  it  was  possible  to  produce  exactly 
opposite  effects  through  the  medium  of  the  very  same  nerves, 
accordmg  as  the  experimental  irritation  applied  to  them  was 
weak  or  strong.  To  Dr.  Handheld  Jones  t  this  seems  a  still 
unanswerable  objection  to  the  inhibitory  theory.  And  in  the 
remarkably  able  and  judicial  summary  of  the  |' Physiology 
and  Pathology  of  the  Sympathetic  or  G-anglionic  System,"  J 
by  Dr.  Robert  T.  Edes,  a  less  decided  but  still  tolerably  strong 
acquiescence  is  given  to  Mr.  Lister's  criticisms  of  this  theory. 
Personally,  I  must  express  very  strongly  the  distrust  (which  is 
probably  felt  by  many  others)  of  doctrines  which  assert  an 
exact  opposition  between  the  functions  of  any  two  nerves,  on 
the  basis  of  an  observation  that  the  same  apparent  effects  may 
be  produced  by  section  of  the  one  and  galvanization  of  the 
other ;  both  processes  seem  far  too  pathological,  and  too  remote 
from  the  conditions  of  ordinary  vitality,  to  admit  of  any  such 
absolute  deductions  from  their  results. 

In  the  present  state  of  our  information  I  am  inclined  to 
explain  all  the  congestive  complications  of  trigeminal  neuralgia 
on  the  basis  of  vaso-motor  paralysis.  And  I  further  believe 
that  the  cause  of  that  paralysis  is  a  direct  extention  of  the  orig- 
inal morbid  process  from  the  sensory  root  to  the  motor,  affect- 
ing the  origin  of  fibres  in  the  latter,  which  are  destined  to 
govern  the  calibre  as  ocular  and  facial  vessels.  These  fibi-es  I 
suppose  it  is  that  Meissner  succeeded  in  dividing  when  he  par- 
tially cut  the  trigeminus,  and  got  nutritive  and  vascular  changes 
without  anfBsthesia. 

There  must  be  more  than  this,  however,  to  account  for  the 
whole  of  the  trophic  phenomena ;  for  there  is  a  great  body  of 
evidence  to  show  that  mere  vaso-motor  paralysis  does  not  pro- 
duce any  phenomena  of  such  an  actively  morbid  kind  as  those 
we  are  endeavoring  to  explain.  The  phenomena  on  the  side 
of  secretion  might  indeed  be  possibly  explained  by  vaso-motor 
paralysis.     [It  must  be  remembered  that  I  am  speaking  of  such 

*  "Deutsches  Arcluv  f.  kiln.  Med.,"  ii.,  2,  1866.  I  am  not  aware 
whether  Piotrowski  has  at  all  altered  his  opinions  since  the  (subse- 
quent) observations  of  Ludwig  and  Cyon  upon  the  "depressor"  nerve. 

f  "  Functional  Nervous  Disorders,"     CliurcUill,  3d  edit.,  1870. 

X  "Prize  Essay  of  the  New  York  Academy  of  Medicine."  New 
York:  Wood  &  Co.,  1869. 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  133 

augmented  secretion  as  is  seen  in  neuralgia.  I  agree  with 
Prof.  Rutherford  (Lectures  on  Experimental  Physiology, 
Lancet,  April  29,  1871)  that  it  is  difficult  thus  to  explain  the 
effects  of  galvanization  of  the  chorda  tympani  on  the  sub- 
maxillary gland.]  Consisting  as  they  do  (a),  in  the  great 
majority  of  cases,  of  a  mere  outpour  of  what  seems  little  more 
than  the  aqueous  part  of  the  secretion,  and  (h)  in  a  few  cases  of 
ari^ested  secretion,  a  phenomenon  otherwise  by  no  means 
unfamiliar  as  the  result  of  sudden,  passive  engorgment  of 
glands.  But  the  mere  cessation  of  vaso-motion  will  not  account 
for  such  facts  as  the  rapid  and  sine  ultaneous  development  of 
erysipelatous  inflammation,  of  corneal  cloudmg  and  ulcera- 
tion, of  hitis  and  glaucoma,  of  nutrition -changes  in  hair  and 
mucous  membrane.  I  must,  for  the  present,  be  content  to 
believe  it  probable  that  there  is  a  special  set  of  efferent  fibres  in 
the  trigeminus,  emanating  from  tlie  motor-root,  whose  ofllce  it 
is  in  some  unknown  way  to  j)reside  over  the  equilibrium  of 
molecular  forces  in  the  tissues  to  which  the  nerve  is  distributed; 
trophic  nerves,  in  fact,  though  not  active  dilators  of  blood- 
vessels. 

It  seems  tome  that,  without  enlarging  further  on  this  almost 
endless  topic,  I  should  be  justified  in  assuming  that  I  had 
shown  the  very  higla  probability  that  the  common  starting- 
point  both  of  the  neui^algia  and  of  its  vaso-moter  secretory,  and 
trophic  complications,  was  in  the  sensory  root  of  the  trigemi- 
nus. But  the  argument  is  greatly  strengthened  when  we  con- 
sider the  fact  that  loss  of  peripheral  common,  and  also  tactile 
sensation,  to  a  greater  or  less  degree,  is  constantly  observed  to 
occur  simultaneously  with  the  pain  and  with  the  other  com- 
plications. When  we  observe  a  patient  suffering  from  rack- 
ing supra-orbital  and  ocular  neuralgia,  and  discover  that  at 
the  very  same  period  the  skin  round  the  eye  is  markedly  insen- 
sitive to  impressions,  except  in  the  points  douleureux,  what 
can  we  rationally  suppose,  except  that  both  pain  and  insensi- 
bility are  the  result  of  one  and  the  same  influence,  which  rad- 
iates frona  the  sensory  centre  ? 

Nor  are  we  likely  to  reach  a  different  conclusion,  if  we  test 
the  matter  by  the  consideration  of  a  rarer,  but  still  sufiiciently 
common  kind  of  case,  such  as  I  have  described  in  Chapter  I. , 
in  which  a  very  strong  peripheral  influence  (traumatic)  pro- 
duces neuralgia,  accompanied  by  vaso-motor  and  secretory  phe- 
nomena, and  by  anaesthesia,  but  not  in  the  district  of  the  pain- 
ful nerve,  but  in  the  territory  of  a  quite  different  nerve.  How 
can  we  doubt,  in  the  case,  e.  g.^  of  a  trigeminal  neuralgia  thus 
complicated,  the  exciting  cause  of  which  was  a  wound  of  the 
ulnar  nerve,  that  the  morbid  influence,  traveling  inward  from 
the  lesion,  Avould  have  passed  without  any  special  consequen- 
ces (as  happens  in  thousands  of  such  nerve- wounds),  had  it 
not,  in  its  passage  along  the  medulla,   encountered  a  locus 


134  PATHOLOGY  Al^D  ETIOLOGY  OF  NEURALGLA.. 

minoris  resistentioR  in  the  roots  of  tlie  trigeminus  ?  It  seems 
impossible  to  account  for  the  phenemena  on  any  other  theory. 
[Eulenburg  says,  in  reference  to  my  reported  cases  of  the  kind : 
"/SoZc/ie  Falle  begunstigeu  in  hohem  Grade  die  Annahme 
pradisponirender  Momente,  die  in  der  ursprunglich  schivach- 
eren  Organisation  einzelner  Abschnitte  des  centralen  Ner- 
ven-apparates  heruhen.''''     Op.  cit.,  p.  56.] 

It  is  necessary,  in  the  next  place,  to  consider  a  very  impor- 
tant question,  how  far  irritation  can  pass  over  from  one  nerve 
to  another,  without  reflection  through  a  spinal  centre,  solely 
in  virtue  of  a  connection  through  the  medium  of  a  nervous 
plexus.  The  case  which  apparently  presents  such  phenomena 
m  the  most  unmistakable  waj^  is  that  of  angina  pectoris. 

The  site  to  which  the  essential  heart-pain  is  referi'ed  in  this 
disea,se  is  probably  the  cardiac,  or  this  and  the  aortic  plexus; 
in  a  comparatively  small  number  of  cases  the  pain  does  not 
extend  farther.  But  much  more  frequently  it  spreads  in  vari- 
ous directions,  and  we  have  to  account  for  its  presence  (a)  in 
intercostal  nerves,  (b)  cervical  nerves,  (c)  nerves  springing 
from  the  brachial  plexus. 

Before  we  inquire  into  the  mechanism  by  which  this  exten- 
sion of  the  pain  takes  place,  w^e  ought  in  strictness  to  ask  our- 
selves whether  the  essential  heart-pain  is  felt  only  in  the 
spinal  sensory  branches,  or  whether  the  sjTnpathetic  fibres  are 
themselves  capable  of  feeling  pain.  The  latter  supposition, 
notwithstanding  all  that  has  been  ai'gued  m  its  favor  from  the 
supiDOsed  analogies  of  the  pain  of  colic,  gall-stone,  etc.,  seems 
to  me  very  doubtful.  It  would  appear  more  probable  that 
both  the  latter  pams,  and  also  those  of  angina,  are  really  con- 
nected with  branches  either  of  the  vagus  or  of  other  spinal 
nerves .  And  there  is  no  need  to  invoke  the  sympathetic  as  a 
sensory  nerve,  to  account  either  for  the  essential  heart-pain 
of  angina,  or  for  its  extension  into  arm,  chest- wall,  and  neck. 
For  the  i^lexus  cardiacus  receives  spinal  branches,  both  from 
the  vagus  and  also  (through  the  medium  of  the  sympathetic 
ganglia  of  the  neck)  from  the  whole  length  of  the  cervical  and 
the  uppermost  pai't  of  the  doi'sal  cord-centres.  And,  in  this 
way,  it  would  seem  quite  possible  intelligibly  to  account  for 
the  pain  radiating  into  intei'costal,  cervical,  and  brachial 
nerves,  merely  by  extension  of  a  morbid  process  essentially 
seated  in  the  cord.  Usually,  however,  one  sees  it  explained 
not  in  this  way,  but  by  the  inter-communications  that  exist 
outside  the  spine,  between  the  branches  from  the  cervical  gan- 
glia and  the  lower  cervical  and  upper  dorsal  nerves;  and  the 
pain  in  the  arm  is  especially  explamed  by  the  connection 
(outside  the  spinal  canal)  of  the  inferior  cervical  ganglion,  on 
the  one  hand  with  the  lower  cervical  nerves,  which  go  to  the 
brachial  plexus,  and,  on  the  other  hand,  with  the  heart  itself. 
There  remains  to  be  explained,  however,  the  singular  tendency 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  135 

of  the  arm-pain  to  be  one-sided  (this  happens  in  at  least  four 
cases  out  of  five) ;  and  this  explanation  seems  to  me  insupera- 
bly difficult,  on  the  theoiy  that  the  transference  of  morbid  ac- 
tion to  the  brachial  nerves  talces  place  through  external  anas- 
tomoses. It  appears  greatly  more  probable  that  angina  is  es- 
sentially a  mainly  unilateral  morbid  condition  of  the  lower 
cervical  and  upper  dorsal  portion  of  the  cord ;  liable  of  course 
to  be  seriously  aggravated  by  such  peripheral  sources  of  irri- 
tation as  would  be  furnished  by  diseases  of  the  heart,  and  espe- 
cially by  diseases  of  the  coronary  arteries ;  the  latter  affection 
probably  involving  constant  mechanical  irritation  of  the  car- 
diac and  the  aortic  plexuses.  It  is  noteworthy  that  the  arm- 
pain  is  sometimes  (I  do  not  know  how  often)  accompanied  by 
vaso-motor  paralysis  in  the  limb ;  this  phenomenon  could  also 
certainly  be  more  easily  accounted  for  on  the  supposition  of 
radiation  from  a  spinal  vaso-moter  centre  (to  which  the  mor- 
bid process  had  extended  from  a  posterior  nerve-root)  than  on 
that  of  communication  between  painful  sensory  nerves  and 
vasomotor,  nerves ;  through  either  of  the  plexuses  independ- 
ently of  the  spinal  centres. 

In  truth,  I  suspect  that,  whatever  part  the  plexuses,  with 
their  reenforcing  ganglionic  cells,  may  play  during  physiolo- 
gical life,  they  are  not  often  the  channels  of  mutual  patliolog- 
ical  reaction  of  one  kind  of  nerve  with  anotiier.  It  would  be 
possible  to  argue  this  even  more  strongly  in  the  case  of  trige- 
minal neuralgias;  but  I  must  not  unnecessarily  expand  this 
already  too  lengthy  discussion. 

From  the  varied  considerations  which  have  now  been 
adduced,  the  reader,  unless  I  altogether  miscalculate  the  value 
of  the  facts,  will  probably  have  arrived  at  the  following  con- 
clusions: (1)  That  the  assumption  of  a  positive  material  cen- 
tric change  as  the  essential  morbid  event  in  neuralgia  is  al- 
most forced  upon  us ;  (2)  that,  whereas  the  morbid  process,  if 
centric,  is  a  priori  infinitely  more  likely  to  be  seated  in  the 
posterior  root  of  the  painful  nerve,  or  the  gray  matter  imme- 
diately connected  with  it,  than  anywhere  else ;  so,  again,  the 
assumption  of  this  locality  will  explain,  as  no  other  theory 
could  explain,  the  singular  variety  of  complications  (all  of  them 
nearly  always  unilateral,  and  on  the  same  side  as  the  pain) 
which  are  apt  to  group  themselves  around  a  neuralgia ;  and 
some  of  which  are  very  seldom  absent  in  neuralgia  of  any 
considerable  severty.  To  this  we  may  certainly  add  that  it  is 
extremely  probable  that  the  vast  majority  of  neurlgic  patients 
inherit  the  tendency  to  this  localized  centric  change ;  in  sup- 
port of  this  we  may  finally  mention  two  considerations  de- 
rived from  the  sex  and  the  ages  most  favorable  to  neui'algia. 
Eulenburg  saw  a  hundred  and  six  cases  of  neuralgia  of  all 
kinds,  of  which  seventy-six  were  in  women  and  only  thirty  in 
men ;  my  own  experience  is  very  similar ;  namely,  sixty-eight 


136  PATHOLOGY  AITD  ETIOLOGY  OF  NEURALGIA 

women  and  thirty-two  men  out  of  a  hundred  hospital  and  pri- 
vate patients.  The  strong  connection  between  the  hysteric  and 
the  neuralgic  temperament  in  women,  and  tlie  great  pi^epon- 
derance  of  women  among  neuralgics,  strengthen  in  no  small 
degree  the  probability  of  inherent  tendencies  to  unstable  eqni- 
librium  as  a*  very  common  jiredisposing  factor  in  neui'algia 
And,  on  the  subject  of  age,  I  need  only  recall  what  I  have  said  so 
strongly  about  the  coincidence  of  neuralgia  with  particular 
epochs  in  life,  as  affording  evidence  of  the  most  powerful  khid 
that  neuralgics  are,  save  in  exceptional  instances,  persons  with 
congenitally  weak  spots  in  the  nervous  centres,  which  break 
down  into  degeneration,  temporary  or  permanent,  under  the 
strains  imposed  by  one  or  other  of  the  physiological  crises  of 
the  organism,  or  the  special  physical  or  psychical  circumstan- 
ces which  surround  the  patient's  life. 

Having  thus  decidedly  expressed  by  belief  in  the  essential 
material  participation  of  the  nerve-centre  in  neuralgia,  it 
remains  for  me  to  discuss  two  points :  first,  as  to  the  character 
of  the  material  change  m  the  nerve-root,  and  next,  as  to  the 
extent  to  which  mere  peripheral  influence,  without  spe- 
cial inherited  tendencies,  may  suffice  to  set  this  process 
going. 

The  raorbid  change  ui  the  nerve-centre  is  probably,  in  the 
vast  majority  of  cases,  an  interstitial  atrophy,  tending  either 
to  recovery,  or  to  the  gradual  establishment  of  gray  degenera- 
tion, or  yellow  atrophy,  of  considerable  portions  of  the  whole 
of  the  posterior  root,  and  the  commencement  of  the  sensory 
trunk  as  far  as  the  ganglion. 

It  is  probable,  however,  that  in  a  certain  number  of  cases,  the 
atrophic  stage  may  be  preceded  by  a  process  of  genuine  inflam- 
mation, and  that  this  inflammation  is  centripetally  produced 
in  consequence  of  inflammations  of  peripheral  portions  of  the 
nerve.  The  considerations  which  make  this  probable  are 
chiefly  derived  from  the  analysis  of  cases  in  which  a  more  or 
less  chronic,  but  severe,  visceral  disorder  has  been  followed  by 
so-called  reflex  paralysis,  but  in  which  neuralgic  phenomena 
have  been  conspicuous.  In  reference  to  this  subject  I  recom- 
mend to  the  reader's  attention  the  very  interesting  paper  on 
"Reflex  Paralyses  "  by  Prof.  Leyden,  of  Konigsberg.*  He  is 
immediately  commenting  upon  a  case  in  which  dysenteric 
affection  of  the  bowel  were  followed  by  the  symptoms  of  mye- 
litis, attended  with  febrile  exacerbations,  and  also  with  severe 
pains  in  the  region  of  the  sacrum,  in  tlie  course  of  the  dorsal 
intercostal  nerves  of  the  right  side,  and  in  the  knees,  and  semi- 
paralytic  weakness  of  the  lower  extremities,  and  with  pains 
between  the  shoulder-blades  and  the  left  arm.  Leyden  dis- 
cusses the  doctrine  of  reflex  paralyses  in  general,  starting  from 

*  Yolkmann's  Sammhmo-  klinisclier  Vortrage,  No.  2.  "  Ueber 
Reflex  La.hmi)ngen,"  von  E.  Lej'den.    Leipzig,  1870. 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA.  137 

the  cases  of  urinary,  paraplegia  brought  forward  by  Stanley,  in 
1835,  and  tracing  the  growth  of  opinion  through  the  phases 
represented  by  Graves,  Henocli,  and  Eomberg,  by  Valentine 
and  Hasse,  then  by  Pfuger,  and  other  professors  of  the  inhibi- 
tory doctrine;  by  Brown-Sequard  (in  his  well-known,  and  now 
very  generally  discredited,  theory  of  spasm  of  the  vessels  in 
the  nervous  centres),  by  Jaccoud  in  the  "  Erschopfung " 
(exhaustion)  theory,  down  to  the  more  careful  and  reliable 
researches  of  Levisson  on  the  temporary  reflected  paralyses 
induced  by  experimental  squeezing  of  the  kidney  or  uterus  of 
animals;  and  then  gives  the  history  of  the  more  recent  doc- 
trine of  a  positive  material  change  in  the  cord  centripetally 
introduced.  Gull*  (1856)  may  be  said  to  have  inaugurated  the 
new  doctrine  of  a  morbid  process  transmitted  along  the  pelvic 
nerves  to  the  cord,  and  causing  material  changes  there. 
Eemak,t  on  the  other  hand,  suggested  a  material  change  oper- 
ating in  the  opposite  direction ;  a  neuritis  descendens,  starting 
in  the  very  nerves  (within  the  pelvis)  which  showed  the  paral- 
ysis in  the  extremities.  The  symptoms  are  supposed  by  hiixi  to 
be  distinctive,  inasmuch  as  there  is  both  violent  pain  in  the 
nerves  of  the  soles  of  the  feet,  and  also  tenderness  of  the  same. 
On  the  other  hand,  Eemak  said  that  myelitis,  with  neuritis, 
might  be  the  or:gin  of  paraplegia  and  simultaneous  palsy  of 
bladder  and  rectum.  The  theory  of  neuritis  descendens  was 
supported  by  Kussmaul,  |  in  the  record  of  a  case  where  disease 
of  the  bladder  was  complicated  with  pelvic  inflammation,  ath- 
eromatous degeneration  of  the  arteries,  and  consequent  fatty 
degeneiation  of  the  sciatic  nerves,  causing  direct  paraplegia. 
We  return  to  the  centripetal  theory  of  urinary  paralysis  with 
Leyden's  own  cases,  piiblished  in  1865 ;  of  three  patients  with 
urinary  paraplegia,  two  died,  and  the  existence  of  a  secondary 
(centripetal)  myelitis  seems  to  have  been  established,  and  by 
all  analogy  it  must  have  existed  in  the  third  case,  which  recov- 
ered. The  only  puzzle  and  doubt  that  ensued  was  caused  by 
the  fact  that  there  was  an  absence  of  neuritis  in  the  different 
nerves  themselves ;  though  it  seemed  plain  that  the  starting 
point  of  the  myelitis  was  at  the  entrance  of  these  nerves  into 
the  cord.  This  mystery  seemed  to  be  cleared  up  by  the  impor- 
tant experiments  of  Tiesler,  ("Ueber  Neuritis  "  Konigsberg, 
1860)  a  pu]3il  of  Leyden's.  This  observer  excited  local  trau- 
matic inflammation  in  the  sciatic  nerve  of  rabbits  and  dogs ; 
the  rabbit  became  paraplegic  and  died  three  days  afterward. 
At  the  site  of  the  artificial  irritation  there  was  a  localized  for- 
mation of  pus,  and  there  was  a  second  similar  formation 
within  the  vertebral  canal  at  the  point  where  the  posterior 

*  "  Cases  of  Urinary  Paraplegia,"  Med.-Chir.  Trans.,  1856. 
f  Wurzburg.  Med,  Zeitsch.,  iv.,  56-64. 
i  Med.  Cent.  Ztg.  21,  1860. 


138  PATHOLOGY  AND  ETIOLOGY  ON  NEURALGIA. 

roots  of  the  sciatic  enter  the  cord ;  but  there  Tvas  no  neuritis 
of  the  intervening  portion  of  the  nerve. 

Upon  this  and  sirailar  evidence  is  based  the  modern  doctrine 
of  a  neuritis  migrans,  with  centripetal  tendencies,  upon  which 
it  is  supposed  that  a  very  large  proportion,  at  least,  of  the 
urinary,  dysenteric,  and  uterine  paraplegias,  miscalled 
"reflex,"  depend;  and  it  ts  clear  that  the  application  of  the 
word  "  reflex  "  in  such  a  case  is  a  gi^ave  abuse,  tending  to  pro- 
duce such  confusion  of  thought  and  error  in  practice.  In  rela- 
tion to  the  subject  of  our  own  inquiry — neuralgia — it  is  ol:)vi- 
ously  of  the  highest  consequence  to  investigate  the  question 
whether  peripheral  irritations,  analogous  to  those  which  pro- 
duce urmary  paraplegia,  are  at  all  frequently  the  cause  of  the 
changes  in  the  posterior  roots  which  produce  true  neuralgia ; 
for  of  course  an  inflammation  may  be  the  beginning  of  an 
atrophy  which  may  presently  exhibit  no  distmction  whatever 
from  one  of  which  the  origin  was  altogether  non-inflammatory. 
I  think  that  there  is  strong  reason  for  thmkmg  that  this  is  not 
at  all  frequently  the  case.  In  the  first  place,  all  tlie  evidence 
that  exists  respecting  these  centripetal  inflammations  of  the 
cord  is  opjDosed  to  the  idea  that,  save  in  the  rarest  instances, 
the  inflammatory  process  limits  itself  to  one  small  segment  of 
the  cord.  Secondly,  the  description  of  the  pains  that  have 
usually  accompanied  such  inflammations  of  the  cord  is  consid- 
erably different  from  the  strictly  localized,  frankly  intermit- 
tent character  of  a  true  neuralgia ;  in  fact,  all  we  know  of  the 
history  of  myelitis  (except  when  complicated  with  a  large 
amount  of  meningitis)  forbids  us  to  suppose  that  severe  pain 
would  be  an  immediate  symptom.  But,  thirdly,  a  far  more 
important  objection  to  the  theory  of  an  origin  in  localized  cen- 
tripetal myelitis,  the  result  of  a  neuritis  migrans,  is  the  rarity 
of  motor  paralysis  as  an  early  symptom,  instead  of  which  we 
ought  to  find  a  very  distinct  history  of  decided  paralysis  (much 
more  decided  than  those  secondary  paralyses  which  actually  do 
occur  in  some  neuralgias)  of  the  muscles  supplied  by  the  ante- 
rior roots  of  the  painful  nerve,  in  every  case  in  which  such  a 
peripheral  origin  could  be  assumed.  Again,  the  totally  fever- 
less  commencement  of  neuralgias,  a  character  which  is  main- 
tained throughout  the  progress  of  the  milder  cases,  is  entirely 
opposed  to  the  idea  of  a  direct  connection  between  myelitis  and 
neuralgia.  The  superficial  appearance  of  pyrexia  is  sometimes 
given  by  a  local  vaso-motor  paralysis,  which  makes  the  neu- 
ralgic part,  after  a  long  bout  of  pam,  hot  and  red ;  but  of  gen- 
eral pyrexia  there  is  nothing. 

Taking  every  thing  into  consideration,  one  is  inclined  to 
say  that  there  is  a  probability  that  in  a  very  limited  number 
of  cases  peri^Dlieral  irritation  does  caase  actual  limited  mye- 
litis, which  escapes  recognition  at  the  time,  but  which  issues 
in  an  atrophy,  the  subjective  expression  of  which  is  actual 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA,  139 

neuralgic  pain.  We  may  well  ask  ourselves,  also,  whether 
there  is  not  some  likelihood  that  a  peripheral  irritation,  wliich 
stops  short  of  producing  an  actual  neuritis  migrans  capable  of 
centripetally  exciting  a  myelitis,  may  not,  by  a  lower  degi'ee  of 
centripetal  irritation,  give  a  bias  toward  certain  forms  of  non- 
mflammatory  atrophy  in  cells  of  posterior  nerve-roots  which 
are  congenitally  of  weak  organization.  I  am  inclined  to 
believe  strongly  that  this  does  occur.  For  exam^^le,  I  should 
explain  thus  the  majority  of  the  peripheral  cases  of  ciliary 
neuralgia,  migraine,  etc. ,  that  we  meet  with  in  poor  young 
needle- women,  especially  the  hypermetropic,  who,  at  an  age 
when  they  can  ill  afford  the  strain,  work  so  constantly  and 
strenuously  at  an  occupation  which  fearfully  taxes  the 
eye. 

I  would  also  go  farther,  and  express  the  opinion  that  peri- 
pheral influences  of  an  extremely  powerful  and  continuous 
kind,  where  they  occur  with  one  of  those  critical  periods  of 
life  at  which  the  central  nervous  system  is  relatively  weak  and 
unstable,  can  occasionally  set  going  a  non-inflammatory 
centric  atrophy  which  may  localize  itself  in  those  nerves  upon 
whose  centres  the  morbific  peripheral  influence  is  perpetually 
pouring  in.  Even  such  influences  as  the  psychical  and  emo- 
tional, be  it  remembered,  must  be  considered  peripheral — that 
is,  they  are  external  to  the  seat  and  centre  of  the  neuralgia. 
And  there  are  probably  few  practitioners  of  lai'ge  experience 
who  have  not  seen  a  patient  or  two  in  whom  the  concurrence 
of  some  unfortunate  psychical  witli  some  other  noxious  peri- 
pheral influence,  the  whole  taking  place  at  some  critical  period 
of  life  (especially  in  the  years  between  puberty  and  marriage), 
seems  to  have  totally  deranged  the  general  balance  of  nervous 
forces,  and  induced  morbid  susceptibilities  and  morbid  tenden- 
cies to  some  particular  neui'osis.  It  is  a  comparatively  fre- 
quent thing,  for  example,  to  see  an  unsocial  solitary  life  Plead- 
ing to  the  habit  of  masturbation),  joined  with  the  bad  influ- 
ence of  an  unhealthy  ambition,  prompting  to  premature  and 
false  work  in  literature  and  art.  The  bad  peripheral  influence 
of  coiistant  fatigue  of  the  eyes  in  study  may  so  completely 
modify  a  young  man's  constitution  as  to  make  a  wreck  of  him 
in  a  very  few  years,  changing  him  from  the  state  of  habitual 
and  conscious  health  to  that  of  chronic  neurosis  of  one  sort  or 
another.  And,  though  it  is  doubtless  on  persons  with  con- 
genial tendencies  to  nervous  diseases  that  such  a  combination 
of  bad  influences  produces  its  most  serious  effects,  yet  there 
unquestionably  are  a  few  persons  in  whom  they  appear  to 
entirely  generate  the  neurotic  constitution.  I  have  already 
touched  upon  the  part  that  misdirected  psychical  influences, 
especially  religious  and  other  forms  of  emotional  excitement, 
may  play  in  this  unfortunate  perversion  of  the  natural 
and  healthy  nervous  functions,   more  especially  in  youth; 


140  PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA. 

and  need  only  add,  here,  that  perhaps  the  most  fatal  com- 
bination of  all  the  bad  influences  is  the  melanchoy  union 
of  "highly-strained  religious  sentiment  with  peripheral  sex- 
ual irritation,  which  is,  unfortunately,  a  too  common  pheno- 
menon under  certain  systems  of  education.  The  most 
frequent  neurotic  consequences  of  the  class  of  influences 
which  have  now  been  referred  to  are  probably  neuralgia — in 
the  form  either  of  migraine,  of  nervous  angina,  or  of  sciatica 
— or  else  asthma. 

But,  if  the  combination  of  several  such  centripetal  influen- 
ces may  generate  the  neurosis  unaided,  even  a  single  one  of 
them  operating  powerfully  for  a  long  period  may  produce 
most  serious  consequences  in  those  who  are  hereditarily  pre- 
disposed. The  influence  of  prolonged  fatigue  of  the  eyesight, 
independently  of  any  special  intellectual  or  emotional  strain, 
was  strongly  illustrated  in  my  own  case  about  three  years  ago. 
I  was  then  engaged  upon  a  piece  of  scientific  writing  which 
demanded  no  great  intellectual  effort,  but  was  being  done 
against  time,  and  by  working,  night  after  night,  many  hours 
by  gas-light.  My  neuralgic  (trigeminal)  attacks  came  on  with 
great  severity,  accompanied  by  vertiginous  sensations  of  so 
alarm.ing  a  kind  as  to  make  me  fear  the  invasion  of  some 
serious  brain-mischief.  I  broke  off  all  work,  and  went  to  the 
sea-side,  but  was  greatly  disappointed  to  find,  for  the  first  few 
days,  that  the  symptoms  were  not  in  the  least  mitigated.  The 
mystery  was  soon  explained.  The  weather  had  been  such  as 
to  confine  me  a  good  deal  to  the  house,  and,  thinking  it  would 
do  no  harm,  I  amused  myself  w^ith  reading  newspapers  and 
novels .  At  last  I  suspected  that  the  use  of  my  eyes  in  read- 
ing was  altogether  mischievous ;  I  desisted  from  reading  any 
thing,  and  in  forty-eight  hours  every  symptom  had  van- 
ished. 

Among  peripheral  influences  of  a  more  mechanical  kind 
there  is  one  cause  of  neuralgia,  the  force  of  which  has  been 
variously  estimated,  but  which  some  authors  rate  as  very 
important,  viz. :  the  influence  of  the  pressure,  and  especially 
of  the  varying  pressure,  of  blood-vessels,  or  other  hollow 
viscera,  upon  the  trunks  of  the  nerves.  We  must  set  aside 
one  such  action  which  is  undoubtedly  very  powerful,  as  essen- 
tially differing  from  the  others ;  I  mean  the  pressure  of  dilated 
blood-vessels,  especially  aneurisms,  when  tlais  happens  to  be 
exerted  upon  the  ganglion  of  the  sensory  trunk.  Here  there 
can  be  no  doubt  of  the  mischief;  for  the  pressure,  if  at  all 
severe,  gradually  destroys  the  life  of  the  ganglion,  upon 
which,  as  was  proved  by  Waller,  the  nutrition  of  the  posterior 
nerve-root  hangs  with  very  intimate  dependence,  and  the  pul- 
sations of  the  vessel  seem  greatlj^  to  aggravate  both  the  irrita- 
tion and  the  centripetal  tendency  to  atrophy.  In  short,  it  is 
plain  that  such  lesion  of  a  ganglion  may  be  the  whole  and 


PATHOLOGY  AND  ETIOLOGY  OF  NEURALGIA,  141 

sufficient  cause  of  a  neuralgia  of  the  most  desperate  and  incu- 
rable kind .  It  is  another  matter  when  we  are  asked  to  believe 
that  the  mere  varying  pressure  of  intestines,  in  different  states 
of  fullness,  or  plexuses  of  pelvic  veins  liable  so  temporary- 
congestions,  can  so  affect  the  sciatic  nerves  as  to  set  up  neural- 
gia. Considering  the  extreme  frequency  of  cases  in  which 
such  momenta  must  be  partially  coming  into  operation,  espe- 
cially in  women — a  frequency  altogether  oat  of  proportion  to 
that  of  sciatica — I  cannot  admit  the  probability  that  this 
influence  is  more  than  an  occasional  and  very  secondary 
factor,  and  that  only  in  cases  whei-e  the  disposition  to  neural- 
gia is  uncommonly  strong. 

A  sufficiently  complete  explanation  of  my  theory  as  to  the 
pathology  and  etiology  of  neuralgia  has  now  been  given, 
although  the  subject  might  be  elaborated  at  far  greater  length ; 
and  I  hope  it  will  be  apparent  to  the  reader  that  the  view  now 
'advocated  is  at  once  important,  and  also  vouched  for  by  strong 
evidence.  I  claim  for  it  that  the  whole  argument  shall  be 
taken  together,  for  it  is  a  case  of  cumulative  proof ;  every  link 
must  be  weighed  and  tested,  before  the  remarkable  strength  of 
the  chain  can  be  felt.  And  it  may  fairly  be  said  that,  if  the 
proof  of  a  definite  kind  of  material  change  in  a  definite  organ, 
as  the  essential  factor  in  neuralgia,  has  been  established  upon 
reasonable  grounds,  an  important  step  has  been  taken  toward 
removing  a  serious  opprobrium  and  difficulty  in  practical 
medicine.  Although  the  true  neuralgias  are  not  among  the 
most  frequent  of  human  diseases,  they  form  a  class  of  enor- 
mous practical  importance,  for  they  are  sufficiently  common  to 
be  sure  to  occur  in  considerable  numbers  in  the  practice  of 
every  medical  man,  and,  both  from  the  suffeiing  v^hich  they 
inflict,  and  the  rebelliousness  which  they  often  show  to  treat- 
ment, they  are  among  the  gravest  sources  of  anxiety  \7hich 
the  practitioner  is  likely  to  encounter.  There  are  probably 
few  disorders  which  so  often  occasion  mortification  and  loss  of 
professional  credit  to  the  physician .  The  helplessness  which 
men,  who  do  not  enjoy  special  oppoi-tunities  of  seeing  those 
diseases  with  frequency,  so  often  show  in  dealing  with  them,  is 
largely  caused  by  the  extreme  timidity  and  vagueness  with 
with  which  the  standard  treatises  on  medicine  deal  with  the 
question  of  their  pathology;  and  a  very  unfair  advantage  has 
thus  been  given  to  the  specialists,  who,  by  the  mere  force  of 
oj)portunity,  and  continual  blind  "pegging  away"  in  an 
entirely  empiric  manner,  have  acquired  a  certain  rude  skill  in 
the  treatment  of  these  maladies  which  enables  them  to  outshine 
practitioners  who  often  have  far  more  in  them  of  the  veritable 
homme  instruit  as  regards  general  scientific  education  and 
habits  of  mind.  It  will  be  evident,  as  a  mere  abstract  proposi- 
tion, that  the  enunciation  of  a  reasonable  pathology  of  the 
disease,   and  the  sweeping  away  of  a  mass  of  unmeaning 


142  DIAGNOSIS  AND  PROGNOSIS  OF  NEURALGIA. 

phrases  about  "mysterious  functional  affections"  and  the 
like,  must  be  a  distinct  gain  to  practitioners  of  plain  common- 
sense  and  good  general  knowledge,  to  whom  neuralgia  is 
merely  one  of  a  vast  number  of  different  diseases  among  which 
their  attention  and  study  are  divided.  And  I  hope  that,  in  the 
further  remarks  on  Diagnosis,  Prognosis,  and  Treatment,  yet 
to  be  made,  the  value  of  clear  pathological  ideas  of  disease  will 
be  brought  more  j^ractically  and  clearly  into  view.  [The 
reader  will  find,  at  the  end  of  Part  I.  of  this  volume,  a  note 
v\diich  contains  a  brief  discussion  on  the  ' '  Ei'schopf  ung  "  theory 
of  Jaccoud,  and  the  doctrines  of  Dr .  Handfield  Jones  respecting 
inhibition,  with  which  I  thought  it  best  not  to  encumber  the 
text  of  the  present  chapter.] 


CHAPTER  IV. 

DIAGNOSIS  AJSTD  PROGNOSIS  OF  NEURALGIA. 

Diagnosis. — This  subject  is  much  simphfied  and  shortened, 
in  regard  to  our  jDresent  purpose,  by  the  plan  of  the  present 
■work,  which,  by  separately  describing  (in  Pai't  II.)  the  other 
disorders  which  resemble  neuralgia,  and  are  liable  to  be  con- 
founded with  it,  avoids  the  necessity  for  stating  here  the 
negative  diagnosis  of  neuralgia  itself.  We  are  only  concerned 
here  to  give  a  clear  x^icture  of  the  positive  signs  which  it  is 
necessary  to  verify  before  we  can  suppose  disease  to  be  neural- 
gia. The  special  modes  of  searching  for  these  are  interesting, 
and  in  some  respects  peculiar ; 

(1)  The  fu'st  and  most  essential  characteristic  of  a  true  neu- 
ralgia is,  that  the  pain  is  invariably  either  frankly  intemiiittent, 
or  at  least  fluctuates  greatly  in  severity,  without  any  sufficient 
and  recognizable  cause  for  these  changes. 

(2)  The  severity  of  the  pain  is  altogether  out  of  proportion 
to  the  general  constitutional  disturbance. 

(3)  True  neuralgic  pain  is  limited  with  more  or  less  distinct- 
ness to  a  branch  or  branches  of  particular  nerves;  in  the 
immense  majority  of  cases  it  is  unilateral,  but  when  bilateral 
it  is  nearly  always  symmetrical  as  to  the  main  nerve  affected, 
though  a  lai'ger  number  of  peripheral  branches  may  be  more 
painful  on  one  side  than  on  the  other. 

(4)  The  pains  are  invariably  aggravated  by  fatigue  or  other 
depressing  pliysical  or  psj^chical  agencies. 

The  above  are  characteristics  wliich  every  genuine  neuralgia 
possesses,  even  in  its  earhest  stages ;  if  they  be  not  present,  we 


DIAGNOSIS  AND  PROGNOSIS  OF  NEURALGIA,  143 

must  at  once  refer  the  diagnosis  to  one  or  other  of  the  aflfec- 
tions  described  in  Part  II.  of  this  work. 

Supposing  the  above  syni^jtoms  to  be  present,  we  expect  to 
find — 

(5)  In  by  far  the  largest  number  of  instances  that  the 
patient  has  either  previously  been  neuralgic,  or  liable  to  other 
neuroses,  or  that  he  comes  of  a  family  in  which  the  neurotic 
disposition  is  well  marked.  Failing  this,  we  are  strongly  to 
doubt  the  neuralgic  character  of  the  malady,  unless  we  detect 
that  there  has  been — 

(6)  A  poisoning  of  the  blood  by  malaria  (but  this  very 
rarely  causes  neuralgia,  save  in  the  congenitally  predisposed) ; 
or— 

(7)  A  powerfully  operating  or  very  long-continued  peripheral 
irritation  centripetally  directed  upon  the  sensory  nucleus  of 
the  painful  nerve ;  which  irritation  may  be  (a)  "functional." 
as  where  the  eye  has  been  persistently  and  severely  over- 
strained and  trigeminal  pain  results,  or  a  sudden  severe  shock 
has  been  received ;  or,  (6)  coarsely  material,  as  where  inflam- 
mation, ulceration,  etc.,  of  surrounding  tissues  involve  the 
periphery  of  the  painful  nerves  in  a  perpetually  moi^bid  action, 
or  chronic  but  profoundly  depressing  psychical  influences; 
or — 

(8)  A  constitutional  syphilis.  In  this  case  there  will  either 
be  marked  syphilitic  local  affection  of  the  trunk  of  a  nerve,  or 
if,  as  is  more  common,  the  syphilitic  change  is  in  the  nerve- 
centre,  there  will  most  likely  be  other  syphilitic  centric  mis- 
chiefs, leading  to  scattered  motor  or  vaso-motor  paralyses, 
characteristic  modifications  of  specicl  sense-functions,  etc. 

If  the  neuralgia  be  of  some  standing  and  a  certain  degree  of 
severity,  there  will  inevitably  be  found — 

(9)  Some  of  the  fixed  tender  points  of  Valleix,  in  such  situ- 
ations as  have  been  described  in  Chapter  I. ;  and — 

(10)  Secondary  afPections  (a)  of  secreting  glands,  or  (6)  vaso- 
motor nerves ;  or  (c)  of  nutrition  of  tissues ;  or  secondary  local- 
ized paralyses  of  muscles,  or  localized  anaesthesia  of  a  some- 
what decided  though  not  complete  kind,  as  described  in  Chapter 
II. ;  any  one  or  any  number  of  these  various  complications  may 
be  present. 

I  must  insist  that  the  above  picture  includes  only  the  essen- 
tials for  a  diagnosis  of  neuralgia ;  if  the  painful  affection  will 
not  answer  to  the  conditions  therein  included,  we  have  no 
right  to  call  it  a  neuralgia — it  belongs,  for  every  practical  pur- 
pose, to  some  other  category  of  disease.  Let  me  add  one  more 
essential .  characteristic,  which  is,  that  the  pain  begins  and 
assumes  its  characteristic  type  before  any  other  of  the  phe- 
nomena appear,  with  the  single  and  partial  exception  of  anae- 
sthesia. 

There  are  some  special  modes  of  diagnosis  of  the  varieties 


144  DIAGNOSIS  AND  PROGNOSIS  OF  NEURALGIA. 

of  neuralgia,  developed  of  late  years,  that  require  notice  liere ; 

they  are  chiefly  the  result  of  the  I'esearches  of  Moriz  Benedikt. 
As  regai'ds  the  quahty  of  the  pain,  Benedikt  says  that  the 
curve  of  intensity  has  an  intimate  relation  to  the  locus  in  quo 
of  the  neuralgia  {i.   e.,   whether  in  the  perij)hery,  trunk,  or 
roots\     An  inflammatory  irritation  set  up  at  the  periphery  of 
<3  nerve  (by  a  joint-inflammation,  for  instance)  produces  a  con- 
tinuous pain ;  the  same  kind  of  ii'ritation,   attacking  a  nerve- 
trunk  (e.  gr.,  in  the  bony  canals),  produces  a  paroxysmal  pahi; 
an  inflammation  spreading  from  the  vertebrte  to  the  nerve- 
roots   or  the  cord-centres  produces   momentary    lancinating 
pains.     The  latter  characteristic  he  supposes  to  be  especially 
charactei'istic  of  the  centrally-produced  neuralgias;  and  I  may 
observe,  as  so  far  confii'matory  of  this  idea,  that  this  is  espec- 
ially the  character  of  the  pains  m  locomotor  ataxy.     There  are 
sundry  special  cases  to  be  considered,  however:  thus,  Benedikt 
himself  remarks  that  the  pain  set  up  by  the  pressure  of  a  pul- 
sating aneurism  is,  from  the  nature  of  tilings,  lancinating  from 
moment  to  moment.     Eulenburg,*  moreover,  says  that  Bene- 
dikt's  tests  of  the  locality  of  the  primary  mischief  only  hold 
good  under  the  following  circumstancs:     (1)  When  the  irrita- 
bility and  the  exhaustibility  of  the  nerves  are  in  a  normal  con- 
dition during  the  neuralgia ;  (2)  when  the  irritation  that  calls 
forth  the  paroxysm  is  either  identical  with  the  original  cause 
of  the  disease,  or  at  least  operates  upon  the  same  spot.     The 
two  conditions,  however,  do  not  concur.     The  irritabihty  and 
exhausibility  may  be  sometimes  excessive  m  neuralgias,  some- 
times normal,  and  perhaps,  in  certain  cases,  beneath  the  nor- 
mal standai'd ;  by  which  means  the  form  of  the  curve  of  inten- 
sity must  be  considerably  modified.     Moreover,   the  irritation 
that  provokes  an  attack  may  from  the  periphery  attack  the 
primary  seat  of  the  disease,   even  when  this  is  central,  on 
account  (says  Eulenburg)  of  exaggerated  conductivity  of  tlie 
nerves  (his  second  causef  of  "hyperaesthesia"),  as  is,  in  fact, 
very  frequently  the   case.     He  also   thinks    the    distinction 
between  paroxysmal  and  lancinating  pains  too  indefinite  to 
serve  as  a  sufficiently  reliable  basis  of  diagnosis,  especially  con- 
sidering the  endless  nuances  of  the  form  which  the  pain  is  apt 
to  take.     I  agree  with  Eulenburg  ujion  this  point ;  and  am  con- 
vinced, from  my  own  obseiwations,  that  such  a  distinction  as 
that  between  lancinating  and  paroxysmal  i^ains  is  illusory,   [I 
have  taken  some  pains  to  investigate  the  character  of  the  pains, 
not  only  in  neuralgia,    but  in  locomotor  ataxy.     It  is  true 
that  the  lancinating  character  predominates,  on  the  whole, 
in  the  latter  disease;    but    there    are    great    differences    m 
different  individuals,  and  even  in  the  same  patient  at  various 

*  Op.  cit.,  pp.  65,  66. 
f  Idem,  p.  8. 


DIAGNOSIS  AND  PROGNOSIS  OF  NEURALGIA.  145 

times,  which  plainly  depend  on  subjective  influences.  Com- 
pare, for  instance.  Dr.  Headlam  Greenhow's  report  on  an 
ataxic  patient,  with  a  report  on  the  same  man  by  Dr.  Buzzard 
and  myself.  ("Trans.  Clin.  Soc,"  vol.  i.,  1868,  pp.  153-162.)  ] 
the  two  kinds  being  frequently  found  altei'nate  in  the  same 
case.  The  only  useful  distinction,  in  my  opinion,  is  Benedikt's 
first  one :  he  is  probably  right  in  saying  that,  where  such  an 
affection  as  an  inflamed  joint  forms  the  source  of  peripheral 
irritation  that  immediately  provokes  a  neuralgia,  the  pain  is 
apt  to  be  unusually  continuous. 

The  extent  to  which  the  pain  of  neuralgia  spreads  into  dif- 
ferent termini  of  the  same  nerve  has  been  made  the  basis  of 
distinctions  as  to  the  seat  of  the  original  mischief.  For  exam- 
ple, it  has  been  said  that  pain  m  the  mental  branch  of  the  third 
division  of  the  trigeminus,  which  does  not  invade  the  auri- 
culo-temporal  branch,  can  hardly  depend  on  an  irritation  oper- 
ating on  the  trunk  of  the  inferior  dental ;  it  must  be  distinctly 
peripheral,  or  else  it  must  act  upon  limited  portions  of  the  cen- 
tral origin  of  the  fifth  nerve.  But  the  fact  seems  rather  to  be 
that,  whether  the  neuralgia  was  excited  by  lesions  at  the  peri- 
phery, in  the  nerve-trunk,  or  in  the  centre,  it  is  equally  possi- 
ble that  either  a  small  or  a  large  part  of  the  peripheral  expanse 
of  the  nerve  may  become  the  seat  of  the  pain :  this  almost  neces- 
sarily follows  from  the  entire  independence  of  individual  fibres 
in  nerves. 

As  regards  the  evidence  afforded  by  the  motor,  vaso-motor, 
and  trophic  complications,  there  is  this  very  positive  diagnostic 
value  in  them — that  they  enable  us  to  say,  with  greater  assur- 
ance than  we  could  otherwise  do,  that  the  disease  is  a  real  neu- 
ralgia. But,  the  only  evidence  that  they  afford  as  to  the  situ- 
ation of  the  mischief  is,  that  they  uniformly  point  to  the  cen- 
tral end  of  a  particular  nerve ;  and  accordingly  I  have  already 
shown,  in  the  chapter  on  Pathology,  that  the  attentive  study 
of  these  very  complications  furnislies  us  with  some  of  the  most 
powerful  arguments  upon  which  rests  my  theory  that  in  neu- 
ralgia there  is  always  centric  mischief.  What  share  in  the 
production  of  the  malady,  in  any  given  case,  has  been  taken 
by  the  centric  disease,  and  what  if  any  by  a  peripheral  irri- 
tation, tlie  existence  of  these  complications  in  no  way  helps  us 
to  determine;  far  less  does  it  enable  us  to  localize  a  peripheral 
lesion  which  may  have  acted  as  a  concomitant  cause ;  on  the 
contrary,  I  believe  that  there  is  no  more  fertile  source  of  eri'on- 
eous  judgment  on  this  very  point,  than  some  of  these  compli- 
cations, especially  the  vaso-motor  and  trophic.  I  suspect  that 
it  has  happened,  m  hundreds  of  instances,  that  a  localized  con- 
gestion or  inflammation,  which  is  a  mere  secondary  phenome- 
non, produced  in  the  centrifugal  manner  already  so  fuiiv 
explained,  has  been  taken  for  the  veritable  fons  et  origo  of 
the  malady:  hence  the  neuralgia  has  been  confidently  reck- 
10 


146  DIAGNOSIS  AND  PROGNOSIS  OF  NEURALGIA. 

oned  as  one  peripherally  procUicecl,  and,  what  is  even  worse, 
the  whole  energy  of  treatment  has  heen  directed  to  a  mere  out- 
lying- symptom,  under  the  idea  that  the  primary  source  of  mis- 
chief was  being  attacked. 

The  application  of  electricity  as  a  test  of  the  nature  of  a 
neuralgia  has  been  em.pl oyed  by  Benedikt,*  who  lays  down  cer- 
tain laws  as  the  result  of  his  researches.  He  say s"^  that  (a)  in 
idiopathic  peripheral  neuralgias  the  nerves  are  not  sensitive  to 
the  ciirrent ;  (6)  in  neuralgias  dependent  on  neuritis  or  hyper- 
semia  of  the  nerve-sheath  there  is  general  electric  tenderness 
of  the  nerve ;  (c;  in  cases  vv'here  the  pain  has  been  set  up  by 
morbid  processes  in  tissues  surrounding  the  nerve,  there  is  elec- 
tric tenderness  only  at  the  site  of  these  changes.  I  may,  in 
general  terms,  express  concurrence  in  these  statements ;  but  I 
must  add  that,  as  diagnostic  rules  they  apply  only  to  the  early 
stages  of  neuralgia;  for  the  occurrence  of  secondary  complica- 
tions may  and  does  altogether  change  the  condition  of  electric 
sensitiveness.  It  need  hardly  be  said  that  the  above  remarks 
on  diagnosis  apply  for  the  most  part  only  to  the  superficial 
neuralgias,  which,  however,  include  an  immense  majority  of 
the  cases  of  neuralgias.  The  diagnosis  of  visceral  neuralgias 
is,  it  need  hardly  be  said,  in  most  cases,  a  far  more  difficult  and 
complicated  matter.  In  these  diseases  we  have  often  little 
more  to  guide  us,  in  the  actual  symptoms,  than  (a)  the  inter- 
mittence  of  the  pain,  and  (b)  the  absence  of  commensurate 
constitutional  disturbance,  especially  the  complete  freedom 
fi'om  sense  of  illness  in  the  intervals  between  the  pains.  We 
shall  be  obliged  to  rely  greatly  on  such  historical  facts  as  the 
presence  or  absence  of  neurotic  tendencies  in  the  patient  and 
his  family ;  the  possibility  of  his  having  been  exposed  to  blood- 
poisoning  (e.  g.,  from  malaria  or  chronic  alcoholic  excess,  or 
extreme  over-smoking) ;  the  circumstance  that  he  has  been 
habitually  oveinvorked,  or  greatly  exposed  to  agitating  psychi- 
cal influences ;  perhaps  that  he  has  been  subject  to  a  combina- 
tion of  several  of  thes^  morbific  momenta.  To  say  truth,  the 
diagnosis  of  visceral  neuralgias  must,  at  the  best  of  times,  be  a 
difficult  and  anxious  matter,  and  we  can  hardly  ever  thor- 
oughly satisfy  ourselves  until  we  have  procured  some  decided 
results  from  treatment;  fortunately,  however,  it  happens 
tolerably  often  that  we  can  do  this,  and  sometimes  in  a  very 
striking  way. 

Prognosis. — The  prognosis  of  neuralgia  varies  exceedingly, 
according  to  the  form  and  situation  of  the  disease,  and  many 
other  considerations.  There  are,  of  course,  in  the  first  place, 
certain  neuralgias  in  which  the  prospect  is  perfectly  hopeless 
OS  to  cure;  such  are  the  cases  in  wb'ch  the  nei've  is  involved 
01  a  continuously  growing  tumor  (especially  within  a  rigid 

*  "ElektroUierapie."     Wien,  18G8. 


DIAGNOSIS  AND  PROGNOSIS  OF  NEURALGIA.  147 

cavity,  like  the  skull),  or  a  slow  but  persistent  ulcerative  pro- 
cess. 

Supposing-,  however,  that  the  case  is  none  of  these,  the  very 
first  prognostic  considei^ation  is  that  of  age. 

Of  the  neuralgias  of  youth,  the  majority  either  disappear 
altogether  after  a  first  attack,  or  recur  a  certain  number  of 
timco  during  some  years,  the  neuralgic  tendency  either  disap- 
pearing or  becoming  greatly  mitigated  when  the  process  of 
bodily  consolidation  is  over.  In  another  group  the  neuralgic 
tendency  is  never  lost,  but  the  form  of  the  attacks  changes,  and 
there  is  far  less  spontaneity  in  the  manner  of  their  production. 
It  is  exceedingly  common  to  see  delicate  boys  and  girls  between 
puberty  and  the  age  of  eighteen  or  twenty,  attacked  with  typi- 
cal migraine,  which  recurs  regulai'ly  every  thz'ee  or  four  weeks 
for  perhaps  two  or  three  years,  then  ceases  to  occur  at  regular 
periods,  then  loses  the  tendei:!cy  to  stomach  complication ;  and, 
by  the  age  of  twenty -five  or  somewhat  later,  has  left,  as  its 
only  relic,  a  tendency  to  attacks  of  ophthalmic  neui'algia,  which 
come  on  when  the  patient  is  excessively  fatigued,  or  encounters 
the  close  air  of  a  theatre,  or  undergoes  an  unusual  strain  of  mental 
excitement  or  anxiety,  etc. ;  but  which  never  come  on  without 
some  such  special  provocation .  So,  again,  there  is  a  variety  of 
sciatica  which  belongs  mainly  to  the  period  between  puberty 
and  the  twenty -fifth  to  thirtieth  year,  and  which  seems  really 
to  belong,  pathologically,  to  the  age  of  unsettled  and  irregular 
sexual  function,  the  tendency  to  it  usually  disappearing  after 
the  patient  has  settled  down  hapijily  in  married  life.  Ovarian 
and  mammary  neuralgia  have  very  commonly  a  similar 
history. 

On  the  other  extreme  we  find  the  neuralgias  of  the  period  of 
bodily  decay:  these  are  of  very  bad  prognosis.  A  neuralgia 
which  first  develops  itself  after  the  arteries  and  capillaries  have 
begun  to  change  decidedly  in  the  direction  of  atheroma  is 
extremely  likely,  even  if  apparently  cured  for  a  time,  to  recur 
again  and  again,  with  ever-increasing  severity,  and  to  haunt 
the  patient  for  the  remainder  of  his  days .  It  therefore  becomes 
exceedingly  important,  m  a  prognostic  point  of  view,  to  assure 
ourselves  as  soon  as  possible  whether  tliis  arterial  degeneration 
has  decidedly  commenced ;  and  for  this  purpose  I  am  in  the 
habit  of  insisting  to  pupils  on  the  great  importance  of  sphyg- 
raographic  examination  for  all  neuralgic  patients  who  have 
passed  the  middle  age.  Where  we  get  the  evidence  which  is 
furnished  by  the  formation  of  a  distinctly  square-headed  radial 
pulse-curve,  even  tliough  there  be  no  palpable  cord-Hke  rigidity 
of  superficial  arteries,  we  are  bound  to  be  exceedingly  cautious 
of  giving  a  favorable  prognosis. 

In  women  the  period  of  involution  of  the  sexual  apparatus 
forms  a  crisis  wliich,  in  regard  to  neuralgias,  is  of  great  prog- 
nostic importance.    On  the  one  hand,  if  the  general  vital  status 


148  DIAGNOSIS  AND  PROGNOSIS  OF  NEURALGIA. 

be  good,  and  the  arterial  system  fairly  unimpaired,  we  may 
look  to  the  completion  of  the  process  of  involution  as  a  proba- 
ble time  of  deliverance  from  neuralgic  troubles  that  have 
hitherto  beset  a  woman ;  we  know  that  she  will  probably  suffer 
a  temporary  aggravation  of  her  pains,  but  we  hope  to  see  her 
lose  them  altogether.  On  the  other  hand,  if  it  should  happen 
that  she  enters  on  the  period  of  sexual  involution  with  her 
general  nutrition  considerably  impau'ed  and  her  arterial 
system  decidedly  invaded  by  atheroma,  it  is  only  too  likely 
that  neuralgias  recurring  now,  or  attacking  her  for  the  first 
time,  will  assume  the  worst  and  least  manageable  type. 

Of  almost  or  quite  equal  importance  with  the  question  of  the 
physiological  age  of  the  patient  is  that  of  his  personal  and 
family  history  with  regard  to  the  tendency  to  neui'algia  and  to 
other  severe  neuroses.  Upon  this  subject  I  have  dwelt  so  very 
fully  in  other  xjarts  of  this  work,  that  it  is  merely  necessary 
here  to  repeat,  that  the  balance  of  chances  is  most  heavily 
swayed  to  the  bad  side  by  all  evidence  tending  to  prove  con- 
genital neurotic  tendencies  in  the  patient  and  vice  versa. 

Of  pixignostic  hints  that  are  to  be  gathered  from  our  knowl- 
edge of  the  immediate  causes  of  the  attack,  there  are  none  so 
valuable  as  those  which  we  gather  from  the  detection  of  a 
malarial  or  a  syphilitic  factor  in  the  production  of  the  malady. 
In  the  former  case,  we  hope  to  cure  the  patient  either  with 
quinine  or  arsenic,  with  almost  magical  certainty  and  rapidity ; 
in  the  latter,  we  expect  an  almost  equally  brilliant  result  from 
iodide  of  potassium. 

The  particular  nerve  in  which  the  neuralgia  is  seated  does 
not  so  decidedly  mfluence  the  prognosis,  according  to  my  expe- 
rience, as  is  stated  by  some  authors;  nevertheless,  there  are 
differences  of  this  kind.  For  mstance,  sciatica,  though  by  no 
means  so  frequently  a  mild  and  trifling  complaint  as  Eulen- 
burg  would  make  it  to  be,  is  certainly,  on  the  whole,  more 
curable  than  the  trigeminal  neuralgias  taken  as  a  group.  I, 
however,  cannot  share  Eulenburg"s  opinion  as  to  the  rarity  of 
a  central  cause  for  sciatica,  nor  his  consequent  explanation  of 
its  more  frequent  curability ;  the  latter  I  explain  by  the  fact 
that  it  is  possible  far  more  completely  to  I'emove  the  concom- 
mitant  causes  in  sciatica  than  in  trigeminal  neuralgia.  By 
simply  keeping  a  sciatic  patient  in  the  prone  posture,  shielded 
from  cold  and  from  pressure  on  the  nerve,  we  have  it  in  our 
power  to  remove  nearly  all  peripheral  sources  of  irritation ; 
but  in  trigeminal  neuralgia  there  are  many  influences,  particu- 
larly psychical  ones,  which  cannot  be  shut  out,  and  which  will 
continue  to  act  with  disastrous  elfect  in  many  cases.  With  all 
this,  however,  we  see  a  suiSciently  large  number  of  incurable 
sciaticas,  on  the  one  hand,  and  of  severe  trigeminal  neuralgia 
cured  on  the  other.  It  is  only  the  genuine  epileptiform  tic, 
occurring  in  subjects  whose  arterial  system  is  an  advanced 


TREATMENT  OP  NEURALGIA.  149 

stage  of  degeneration,  that  stands  out  clearly  and  unmistakably 
pre-eminent  among  neuralgias  for  rebelliousness  to  treatment 
of  every  kind. 


CHAPTER  V. 

TREATMENT  OF  NEURALGIA. 

I  now  approach  what  is  really  the  most  difficult  portion  of 
my  task ;  for,  although  it  would  be  easy  enough  to  write  copi- 
ously on  the  treatment  of  neui^algia,  it  is  extremely  difficult  to 
keep  a  just  medium  between  the  opposite  extremes  of  undue 
meagreness  and  of  useless  profusion  of  detail  in  the  handling 
of  this  subject.  There  are  also  difficulties  connected  with  the 
present  uncertain  and  transitional  state  of  opinion,  even 
among  high  authorities,  as  to  the  value  of  particular  remedies, 
and  even  of  large  groups  of  remedial  agents,  altogether  there 
has  been  more  hesitation  in  ray  mind  as  to  this  part  of  the 
jDi'esent  work  than  about  any  other,  and  the  present  chapter 
has  been  rewritten  more  than  once.  I  mention  this  only  to 
account  for  what  there  may  very  likely  be  found  in  it — an 
imperfect  literary  style  such  as  too  commonly  marks  work  which 
has  been  repeatedly  patched  and  corrected.  At  the  same  time, 
it  should  be  said  that  my  hesitation  does  not  apply  to  the  main 
principles  of  treatment  which  will  be  recommended  below ;  it 
proceeds  rather  from  the  fear  of  seeming  to  ignore  from  care- 
lessness modes  of  treatment  which  are  still  much  used,  but 
which  I  have  really  rejected,  because,  after  full  trial,  they 
api^eared  to  me  valueless.  Space  is,  after  all,  limited,  and  a 
complete  account  of  all  the  remedies  for  neuralgia  in  vogue, 
in  English  and  Continental  clinics,  would  of  itself  fill  a  large 
volume. 

The  treatment  of  neuralgia  may  be  divided  into  four 
branches:  (1)  Constitutional  remedies;  (2)  narcotic-stimulant 
remedies;  (3)  local  applications;  (4)  prophplaxis. 

1.  Constitutional  treatment  must  be  subdivided,  as  (a)  diet- 
etic, (b)  anti-toxic,  and  (c)  medicinal  tonic. 

(a)  The  importance  of  a  greatly-improved  diet  for  neuralgic 
patients  is  a  matter  which  is  more  fully  appreciated  by  the 
English  school  of  medicine  than  by  either  the  French  or  the 
German;  it  has,  for  instance,  very  much  surprised  me  to 
notice  the  almost  entire  silence  of  Eulenburg  on  this  topic. 
For  my  part,  the  opinions  expressed  three  years  ago*  on  this 
matter  have  only  been  modified  in  the  direction  of  increasing 

*Art.  "Neuralgia"  ("Reynold's  System  of  Medicine,"  vol.  ii.  1868.) 


150  TREATMENT  OP  NEURALGIA. 

certainty ;  I  have  learned  by  further  experience  that  the  prin- 
ciple is  even  more  extensively  applicable  than  I  had  supposed. 

That  neuralgic  patients  require  and  are  greatly  benefited  hj  a 
nutrition  considerably  richer  than  that  which  is  needed  by 
healthy  persons,  is  a  fact  which  corresponds_  with  what  may 
be  observed  respecting  the  chronic  neuroses  in  general ;  and  it 
gives  me  much  satisfaction  to  point  out  this  position  of  neu- 
ralgia as  belonging  to  this  large  class  of  disorders,  not  merely 
by  its  pathological  affinities,  but  by  its  nutritive  demands.  _  In 
a  very  excellent  and  suggestive  paper  by  Dr.  Blandford*  it  is 
stated,  as  the  result  of  a  large  experience  in  mental  and_  other 
nervous  disorders,  that  the  greater  number  of  <;hronic  insane 
and  hypochondrical  cases,  as  well  as  neuralgic  patients,  are 
remarkably  benefited  by  what  might  seem  at  first  sight  almost 
a  dangerously  copious  diet.  Occasionally  it  happens  that  the 
patients  discover  this  by  the  teaching  of  their  own  sensations, 
and  the  apparent  excesses  in  eating  which  some  epileptic  and 
hypochondriacal  persons  habitually  commit  are  looked  on  by 
many  practitioners  as  the  mere  indications  of  a  morbid  bulimia 
which  represents  no  real  want,  but  only  the  craving  of  a  per- 
verted sensation  which  ought  to  be  interfered  with  and  allayed 
rather  than  encouraged.  It  is  now  many  years  since  1  began 
to  doubt  the  justice  of  this  opinion ;  the  particular  instance 
which  called 'my  attention  to  it  being  that  of  epilepsy,  of  which 
disease  I  saw  a  considerable  number  of  cases,  within  a  short 
period  of  time,  that  were  distinguished  by  the  presence  of 
enormous  appetite  for  food ;  and  I  finally  came  _  to  the  conclu- 
sion that,  so  far  from  this  symptom  being-  of  evil  augury,  and 
likely  to  lead  to  mischief,  it  is,  with  certain  limitations,  a  most 
fortunate  occurrence.  It  is  hardly  necessary  to  say  that  over- 
eating, such  as  produces  dyspepsia  and  distention  of  a  torpid 
intestine  w^ith  masses  of  fseces,  may  distinctly  aggravate  the 
convulsive  tendency;  but  the  truth  is  that,  with  a  little  careful 
direction  and  management  of  the  unusual  appetite,  these  buli- 
mic patients  can  in  most  cases  be  allowed  to  satisfy  their  desires 
without  harm  of  this  kind  following;  a  larger  portion  of  food 
really  gets  applied  to  the  niitritive  needs  of  the  body,  and  the 
nervous  system  unmistakably  benefits  thereby,  the  tendency 
to  atactic  disorder  being  visibly  held  in  check . 

That  which  I  have  thus  observed  in  the  case  of  epilepsy,  and 
which  Dr.  Blandford  more  particularly  affirms  concerning 
chronic  mental  diseases  and  the  large  number  of  neuroses  that 
hover  on  the  verge  of  insanity,  has  been  most  distinctly  veri- 
fied in  my  experience  of  the  treatment  of  neuralgia.  It  is, 
unfortunately,  by  no  means  a  frequent  occurrence  that  the 
suflcerer  from  this  malady  is  inclined  to  eat  largely,  but  the 
few  patients  of  this  type  that  I  have  seen  were,  in  my  judg- 

*  Practitioner,  vol.  iv,,  1870. 


TREATMENT  OF  NEURALGIA.  151 

ment,  distinctly  the  better  for  it.  Far  more  common  in  neu- 
ralgia is  a  disposition  of  the  patient  to  care  little  for  food,  to 
become  nice  and  dainty,  and  in  particular  to  develop  an  aver- 
sion— partly  sensational  and  partly  the  result  of  morbid  fear 
about  indigestion — for  special  articles  of  diet.  Dr.  Radclilfc 
pointed  out  the  special  tendency  of  neuralgics  to  neglect  all 
kinds  of  fat;  partly  from  dislike,  and  partly  because  they 
believe  it  makes  them  ' '  bilious ;"  and  I  have  had  many  occa- 
sions to  observe  the  correctness  of  this  observation.  In  fact, 
by  the  time  patients  have  become  sufficiently  ill  vs^ith  neural- 
gia to  apply  to  a  consulting  physician,  they  have  already,  in 
the  great  majority  of  cases,  got  to  reject  all  fatty  foods,  and 
have  cut  down  their  total  nutrinient  to  a  very  suiiicient  stand- 
ard .  Young  ladies  suffering  from  migraine  are  especially  apt 
to  mismanage  themselves,  to  a  lamentable  extent,  in  this  direc- 
tion: this  is  natural  enough,  because  the  stomach  disorder 
seems  to  them  the  origin  of  the  pain,  instead  of  being,  as  it  is, 
a  mere  secondary  consequence  of  the  neurosis.  But  it  is  not 
only  the  sufferers  from  sick-headache  in  whom  we  find  this 
tendency  to  insufficient  eating,  especially  of  fat ;  not  to  men- 
tion that  all  severe  pain  usually  tends  to  disorder  appetite  and 
make  it  fastidious,  there  is  nearly  always  some  wiseacre  of  a 
friend  at  hand,  ready  to  suggest  that  neuralgia  is  something 
very  like  gout,  that  gout  is  always  aggravated  by  good  living, 
and,  ergo^  that  the  patient  should  be  "extremely  cautious  as 
to  diet;"  the  end  of  which  is  that  the  poor  wretch  becomes  a 
half -starved  valetudinarian,  but,  so  far  from  his  pain  getting 
better,  it  steadily  becomes  worse.  I  cannot  too  strongly  express 
the  benefits  that  I  have  seen  accrue,  in  the  most  various  kinds 
of  neuralgic  cases,  from  persistent  efforts  to  remedy  this  state 
of  things,  and  to  convert  tlae  j)atient  from  a  valetudinarian  to 
a  hearty  eater ;  and  I  wish  particularly  to  say  that  this  success 
has  always  been  most  marked  when  I  have  from  the  first 
insisted  on  fat  forming  a  considerable  element  of  the  food. 
Cod-liver  oil  is  the  form  in  which  I  much  prefer  to  give  it,  if 
this  be  possible ;  there  can  be  no  mistake  about  the  relatively 
greater  power  of  this  than  of  any  otlier  fatty  matter,  I  believe 
simply  from  its  great  assimilability.  But  the  very  cases  in 
which  we  most  urgently  desire  to  give  fat  are  often  those  in 
which  the  patient's  fantastic  stomach  openly  revolts  at  the 
idea  of  the  oil ;  we  must  then  try  other  fats ;  and  we  should  go 
on  trying  one  thing  after  another — butter,  plain  cream,  Devon- 
shire cream,  even  olive  or  cocoanut  oil  (though  these  are  the 
poorest  things  of  the  sort  we  can  use) — till  we  get  the  patient 
well  into  the  way  of  taking  a  considerable,  if  possible  a  decid- 
edly large,  daily  allowance  of  fat,  without  provoking  dyspep- 
sia. It  is  surprising  what  can  be  done  in  this  way  by  perse- 
verance and  tact,  and  it  is  no  less  striking  to  observe  the  good 
effects  of  the  treatment.     Nothing  is  more  singular  than  to  see 


152  TREATMENT  OP  NEURALGIA. 

a  g-irl,  who  was  a  peevish,  fanciful,  and  really  very  suffering 
migraineuse,  brought  to  a  state  in  which  she  will  eat  spoonful 
after  spoonful  of  Devonshire  cream,  and  at  the  same  time  lose 
her  headaches,  lose  her  sickness,  and  develop  the  appetite  of  a 
day-laborer;  and,  though  such  very  marked  instances  as  this 
are  tmcommon,  they  do  sometimes  occur,  and  a  minor  but 
still  important  degree  of  improvement  is  very  frequent . 

As  for  the  modus  operaridi  of  the  fatty  food,  there  is  no  cer- 
tainty. Dr.  Radcliffe  believe  it  acts  as  a  direct  nutrient  of  the 
nervous  centres ;  and  I  also  cannot  help  feeling  that  there  is 
some  evidence  in  favor  of  this  idea.  But,  whether  this  be  so 
or  not,  there  is  another  kind  of  action  of  fat  that  is  more  sim- 
ple and  obvious ;  namely,  it  seems  to  be  certain  that  the  en- 
richment of  the  diet  by  fat  greatly  assists  the  assimilation  of 
food  in  general,  and  thus  the  patient's  ni^trition  is  altogether 
improved. 

It  is  not  merely,  however,  by  increasing  any  one  element  of 
food  that  we  should  seek  to  enrich  the  diet  of  neuralgics,  but 
rather  by  such  a  steady  and  persistent  effort  as  Dr.  Blandford 
describes,  to  increase  the  total  quantity  of  nutriment  to  j)erhaps 
as  much  as  one-third  more  than  the  patient  would  probably 
have  taken  in  health.  To  those  who  from  prejudice  are  in- 
credulous of  the  propriety  of  this  method,  I  would  say,  "Try 
it,  and  I  venture  to  say  your  incredulity  will  disappear." 
More  especially  I  would  urge  the  great  importance  of  this 
system  in  modifying  the  nervous  status  of  very_  young,  and 
also  of  aged,  sufferers  from  neuralgia;  it  is  the  indispensable 
basis  of  a  sound  treatment  for  such  patients. 

This  seems  the  proper  place  for  such  remarks  as  must  be 
made  upon  the  function  of  alcohol  in  neuralgia;  for,  though 
this  agent  is  a  true  narcotic  when  given  in  large  doses,  it  is  not 
under  that  aspect  that  I  can  recommend  its  use  in  neuralgia  at 
all.  I  have  written  so  much  on  this  subject  lately,  that  I  shall 
here  content  myself  with  an  emphatic  repetition  of  my  protest 
against  the  use  of  alcoholic  liquors  as  direct  remedies  for  pain. 
They  ought  only  to  be  given,  in  neuralgia,  in  such  moderate 
doses,  with  the  meals,  as  may  assist  primary  digestion  without 
inducing  any  torpor,  or  flushing  of  the  face,  or  artificial  exhil- 
aration. I  cannot  too  exj)ressly  reprobate  the  practice  of 
encouraging  neuralgics,  especially  women,  to  relieve  pain  and 
depression  by  the  direct  agency  of  wine  or  spirit ;  it  is  a  system 
fraught  with  dangers  of  the  gravest  kind. 

(6)  The  anti-toxic  remedies  include  agents  addressed  to  the 
modification  of  a  special  condition  of  the  blood  and  tissues 
induced  by  the  presence  of  morbid  poisons,  of  which  syphilis, 
malaria,  and  (more  doubtfully)  gout  and  rheumatism,  are  the 
representative  examples. 

Of  syphilitic  neuralgia  the  treatment  may  be  summed  up  in 
a  few  words:    Give  iodide  of    potassium    in  doses    rapidly 


TREATMENT  OF  NEURALGIA.  153 

increased  up  to  a  daily  quantum  of  twenty  to  thirty  grains.  If 
this  fails,  give  one-twelfth  of  a  grain  of  bichloride  of  mercury 
thrice  daily. 

Of  malarial  neuralgia  I  can  only  speak  from  such  a  limited 
experience  that  I  am  by  no  means  in  a  position  to  give  an 
exhaustive  account  of  the  treatment.  Quinine  is,  of  course, 
the  remedy  that  should  first  be  tried ;  and,  as  the  paroxysms 
are  usually  regular  in  their  recui^rence,  I  prefer  to  give  the 
drug  after  the  plan  which  is,  I  thnik,  incontestably  the  best  in 
ordinaiy  ague— 1  e.,  to  administer  one  large  dose  (five  to 
twenty  grains)  about  an  hour  before  the  time  when  the  attack 
is  expected.  With  a  few  exceptions  the  malady,  unless  it  had 
taken  very  deep  root  before  we  were  consulted,  will  yield  to  a 
few  doses  given  in  this  way;  after  the  morbid  sequence  has 
been  thus  interrupted,  it  will  be  proper  to  continue  the  action 
of  quinine  in  smaller  and  more  frequent  doses,  given  for  three 
or  four  weeks  continuously.  For  the  comparatively  rare  cases 
in  which  quinine  fails,  the  prolonged  wse  of  arsenic  (Fowler's 
solution,  five  to  eight  minims  three  times  a  day),  especially 
with  the  simultaneous  employment  of  codliver  oil,  is  to  be 
recommended. 

The  part  which  gout  may  play  in  inducing  neuralgia  is,  as  I 
have  already  said,  a  far  more  doubtful  question  than  the  pop- 
ular medical  traditions  assume  it  to  be ;  and  treatment  directed 
to  gout  as  a  cause  is  an  extremely  uncertain  affair.  The  direct 
relief  of  neuralgic  pain  by  the  administration  of  colchicum,  for 
example,  is,  in  my  experience,  a  very  rare  occurrence,  even 
where  the  gouty  diathesis  is  unmistakably  present;  and,  on 
the  other  hand,  the  depressed  vitality  which  gouty  neuralgics 
usually  show  in  a  marked  degree,  renders  it  very  doubtful 
whether  the  relief  of  the  pain  may  not  be  too  dearly  purchased 
at  the  cost  of  the  general  lowering  effects  of  colchicum.  It  is 
probable  that  neuralgia  occurring  in  gouty  subjects  is  more 
safely,  and  equally  eff  actually,  treated  upon  general  principles. 
At  the  same  time  it  may  be  admitted  that,  in  the  subordinate 
function  of  an  adjuvant  to  the  aperients  which  it  is  sometimes 
advisable  to  give,  small  doses  of  the  acetic  extract  of  colchicum 
seem  to  possess  some  value. 

The  question  of  treatment  addressed  to  a  supposed  rheumatic 
element  in  neuralgia  will,  of  course,  be  differently  judged 
according  to  the  respective  ideas  of  various  practitioners  as  to 
the  pathological  affinities  of  the  two  diseases ;  and  the  reader 
already  knows  that  I  believe  these  affinities  to  be  different  in 
kind  from  what  is  generally  believed.  The  utmost  that  I 
should  concede  is,  that  in  a  certain  very  limited  number  of 
cases  the  peripheral  factor  in  neuralgia  is  an  inflammation  of 
the  nerve-sheath,  or  surrounding  tissues,  which  forms  part  of  a 
chain  of  phenomena  of  local  fibrous  inflammations  in  different 
parts  of  the  body.     Iodide  of  potassium,  in  five  or  ten  grain 


154  TREATMENT  OF  NEURALGIA. 

doses  three  times  a  day,  is  the  proper  treatment  for  such  cases. 
I  have  never  found  alliahes  do  any  direct  good  to  the  pam. 

(c)  The  medicinal  tonic  variety  of  constitutional  treatment  is 
more  especially  represented  by  the  use  of  iron  and  arsenic  in 
cases  where  poverty  of  the  blood  seems  to  exist  in  a  marked 
degree,  and  by  the  administration  of  certain  tonics — quinine, 
phosphorus,  strychnia,  and  zinc— v?hich  are  supposed  to  exert 
a  specially  restorative  influence  upon  the  nervous  tissues. 

The  use  of  quinine  as  an  anti-malarial  agent  has  been  already 
referred  to ;  its  employment  in  non-malarial  cases  is  of  much 
m.ore  restricted  scope  and  benefit.  Experience  has  taught  me 
to  agree  in  general  with  the  opinion  of  Valleix,  that  it  is  a 
very  unreliable  agent ;  the  one  marked  exception  to  this  being 
the  case  of  ophtlialmic  neuralgias.  Vf  hat  the  reason  may  bo 
I  cannot  in  tlie  least  say,  but  it  is  a  fact  that  quinine  does  ben- 
efit these  neuralgias,  in  cases  where  there  is  no  room  for  suspi- 
cion of  malaria,  witli  a  frequency  which  is  very  much  greater 
than  in  the  treatment  of  the  painful  affections  of  any  other 
nerve  iii  the  body.  The  quantity  given  should  be  about  two 
grains  three  times  a  day. 

The  preparations  of  phosphorus  v/hich  I  have  employed  in 
the  treatment  of  neuralgia  are  the  phospliuretted  oil,  the  hypo- 
phosplute  of  soda  (five  to  ten  grains  three  times  a  day),  and 
pills  of  phosphorus  (according  to  Dr.  Radcliffe's  recommenda- 
tion) containing  one-thirtieth  of  a  grain,  given  twice  or  thrice 
daily.  Either  of  the  two  last  will  do  all  that  phosphorus  can 
do,  but  its  utility  is  not  very  extensive  or  reliable.  I  have 
found  it  to  do  most  good  in  cases  where  there  was  a  high 
degree  of  ansesthetic  complication. 

Pre]Darations  of  zinc  have,  in  my  hands,  done  no  particular 
good,  although  I  have  tried  them  in  all  manner  of  doses. 

Strychnia,  on  the  other  hand,  is  a  remedy  which  I  have 
learned  to  prize  much  more  highly  during  the  last  few  years 
than  previously.  Its  most  decided  efficacy  has  been  shown  in 
some  of  the  visceralgite,  especially  gastralgia,  and  (to  a  less 
extent)  angina  pectoris.  Its  internal  use  for  these  complaints 
is  iDCst  effected  by  giving  doses  of  five  to  ten  minims  of  tincture 
of  nux- vomica  three  times  a  day ;  but  a  method  which  I  have 
several  times  employed  with  good  effect  is  the  subcutaneous 
injection  of  very  small  doses  of  strychnia  (one-eightieth  to  one- 
fiftieth  of  a  grain)  twice  daily.  For  the  superficial  neuralgias, 
on  the  other  hand,  I  generally  administer  one-fortieth  of  a 
grain,  with  ten  or  fifteen  minims  of  tincture  of  sesquichloride 
of  iron,  by  the  stomach,  three  times  a  day ;  this  is  a  very  pow- 
erful prophylactic  remedy  to  prevent  the  recurrence  of  the 
attacks  when  once  the  sequence  of  them  has  been  broken 
through  by  other  means. 

Of  iron  generally,  as  a  remedy  in  anaemic  cases,  I  have  only 
to  remark  that,  in  order  to  get  its  full  benefits,  it  is  necessary 


TREATMENT  OF  NEURALGIA.  155 

to  use  large  doses.  I  give  the  saccharated  carbonate  in  twenty- 
grain  doses  twice  or  three  times  a  day. 

But  of  the  sesquichloride  of  iron  I  am  inchned  to  say  some- 
thing more ;  it  has  seemed  to  me  that,  besides  its  effects  on  the 
blood,  it  has  a  marked  and  direct  influence  upon  the  nervous 
centres,  which  is  different  from  anything  v/hich  one  observes 
in  the  action  of  other  preparations  of  iron.  It  is  certain  that 
the  action  of  sesquichloride  of  iron,  in  those  cases  of  chlorosis 
which  are  distinguished  by  profound  nervous  depression,  is 
soraething  quite  peculiar ;  and  the  effect  which  it  produces  in 
theansemic  neuralgias,  more  especially  of  young  women,  is 
equally  remarkable.  I  cannot  help  alluding  here  to  the 
striking  effects  which  large  doses  of  the  tincture,  as  recom- 
mended by  Dr.  Reynolds,  produce  in  acute  rheumatism ;  the 
severest  pain  is  often  checked  within  twenty-four  hours  after 
the  commencement  of  this  treatment.  Both  in  this  disease  and 
m  neuralgia,  I  employ  the  old-fashioned  tinctui'e :  if  given 
alone  it  should  be  used  in  large  doses  (thirty  or  forty  minims 
three  times  a  day) ;  but  an  excellent  combination  is  that, 
already  mentioned,  of  ten-minim  doses  of  this  tincture  with 
one-fortieth  of  a  grain  of  strychnia.  There  is  something  in  the 
revivifying  effects  of  this  mixture  that  is  quite  peculiar.  I 
have  very  lately  employed  it  in  the  case  of  a  gentleman,  aged 
thirty-five,  who  was  the  subject  of  frontal  neuralgia  compli- 
cated with  paralysis  of  the  internal  rectus,  and  who  was 
decidedly  ansemic,  and  greatly  depressed  and  worried  in  mind 
by  the  consciousness  of  his  inability  to  overtake  professional 
work  which  had  accumulated  upon  him.  This  patient  improved 
with  great  rapidity,  and  in  the  course  of  three  weeks  lost,  not 
merely  his  neuralgia,  but  also  his  strabismus,  almost  entirely; 
but  he  then  got  into  a  condition  which,  though  not  of  per- 
manent importance,  was  sufficiently  undesirable  to  make  me 
mention  it  here,  especially  as  I  have  seen  the  same  thing  in 
more  than  one  patient  besides  him.  It  is  a  peculiar  state  of 
restlessness  during  the  day  and  sleeplessness  at  night,  without 
any  positive  exaltation  of  reflex  excitability  such  as  one  used 
to  see  from  strychnia  in  the  days  when  mischievously  large 
doses  of  that  drug  were  very  commonly  given,  and  patients 
used  to  complain  of  decided  twitchings  and  starlings  of  the 
limbs.  It  is  clearly  not  a  strychnia  effect  pure  and  simple, 
nor  an  iron  effect  only ;  it  is  a  tertium  quid  compounded  of 
the  actions  of  both  drugs. 

The  direct  effects  of  arsenic  in  the  improvement  of  the 
quality  of  the  blood  seem  to  me  incontestable ;  and  its  use  for 
this  purpose  in  ansemic  neuralgias  is  certainly  soraething  over 
and  above  its  special  neurotic  action.  No  one,  who  has 
employed  it  much  in  the  cases  of  anaemic  children  suffering 
from  chorea  after  rheumatism,  can  have  failed  to  observe  its 
frequently  striking  influence  upon  blood-formation  even  long 


156  TREATMENT  OF  NEURALGIA. 

before  the  nervous  ataxia  is  materially  reduced.  The  niisfor- 
tune  is,  however,  that  we  possess  no  indications  by  which  to 
judge  beforehand  whether  we  may  reckon  on  its  xnost  favor- 
able action  in  any  given  (non-malarious)  case,  with  certain 
special  exceptions.  In  angina  pectoris  it  has  a  most  dhect 
effect,  which  is  rarely  altogether  missed,  and  is  sometimes 
surprising :  the  cases  in  which  it  succeeds  best  are  those  dis- 
tinguished by  anaemia,  but  we  may  well  suppose,  from  its 
remarkable  action  upon  other  neuroses  of  the  vagus,  that  it  is 
something  more  than  an  action  on  the  blood-making  process 
which  produces  such  powerful  effects  ia  allaying  the  tendency 
to  recurrence  of  the  paroxysms.  My  attention  was  called  to 
its  action  in  this  disease  chiefly  by  the  remarkable  case  pub- 
lished by  Philipp;*  this  was  a  purely  neurotic  angina,  but  one 
of  the  sevei'est  type,  and  the  influence  of  arsenic  was  very 
striking.  Since  ihat  time  I  have  employed  it  in  several  cases, 
and,  after  trying  various  forms  of  administration,  I  conclude 
that  nothing  is  better  than  Fowler's  solution,  in  does  of  three 
minims  (gradually  increased,  if  the  remedy  be  well  tolerated, 
up  to  eight  or  ten)  three  times  a  day.  Unfortuiiately,  there 
are  some  neurotic  patients  who  cannot  bear  arsenic,  the  irrita- 
bility of  their  alimentary  canal  is  such  that  the  drug  always 
provokes  vomitmg,  or  diarrhoea,  or  both;  this  was  the  case 
with  one  of  my  patients,  in  whose  case  I  had  allowed  myself  to 
hope  for  the  very  best  results  from  arsenical  treatment.  But 
where  the  patient  tolerates  it — and  ustially  he  tolerates  it 
extremely  well— the  prolonged  use  of  arsenic  seems  really  to  root 
out  the  anginoid  tendency,  or  at  least  to  confine  it  to  the  more 
trivial  and  manageable  manifestations.  I  believe  that  in  at  least 
three  patients,  I  have  so  completely  broken  down  a  succession 
of  cardiac  neuralgic  attacks  as  to  substitute  for  them  a  mere 
remnant  of  a  tendency  to  "  tightness  at  the  chest"  after  any 
severe  bodily  exertion  or  mental  emotion.  It  might  be  a  ques- 
tion, in  cases  where  the  stomach  does  not  tolerate  the 
ordinary  administi*ation  of  the  agent,  whether  it  would 
not  be  worth  while  to  try  the  effect  of  subcutaneous 
injection  (two  to  four  minims  of  Fowler),  or  inhalation  of  the 
smoke  of  arsenical  cigarettes.  But,  in  truth,  it  is  not  certain 
that  even  in  this  case  we  escape  the  characteristic  effects  of 
the  drug  upon  those  persons  who  are  abnormally  sensitive  to  it. 
A  remarkable  instance  of  the  beneficial  influence  of  arsenic 
occurred  in  the  case  of  a  woman,  aged  forty-six,  the  solitary 
example  of  severe  angina  in  a  female  that  I  have  ever  seen. 
[It  is  by  no  means  uncommon,  however,  to  see  the  milder 
forms  of  cardiac  neuralgia  in  women;  the  remarkable  statistics 
of  Forbes,  quoted  in  Chapter  I.,  must  certainly  have  been 
taken  exclusively  from  cases  of  the  severest  type  of  the  disease.] 

*  Berlin,  kliu.  Wochensch.,  1865. 


TREATMENT  OF  NEURALGIA.  157 

This  was  a  hospital  patient,  who  had  always  suffered  much 
from  hysteria,  and  from  childhood  had  been  liable  to  hemi- 
cranic  headache;  she  had  entered  on  the  period  of  "  change" 
at  the  time  the  attacics  began,  but  menstruation,  though  irre- 
gular, still  continued,  and,  in  fact,  did  not  cease  till  four  years 
later,  long  after  the  anginal  attacks  had  been  subdued.  The 
patient  had  been  attacked  for  the  first  time  at  the  end  of  a 
heavy  day's  washing;  she  dropped  on  the  ground  with  the 
sudden  agony  and  f aintness,  and  thought  she  should  ' '  never 
come  to  life  again."  Tlie  paroxysms  returned  five  times  within 
the  next  month,  though  not  always  so  severely  as  on  the  first 
occasion ;  but  the  poor  woman  lived  in  a  constant  state  of 
terror.  On  the  occasion  of  her  second  visit  to  me,  she  had  a 
raost  severe  attack  in  the  waiting-room  at  the  hospital :  being 
called  to  her  I  found  her  very  nearly  pulseless,  gasping,  and 
with  the  kind  of  complexion  which  is  so  suggestive  of  approach- 
ing death.  She  was  recovered  by  a  large  dose  of  ether.  It 
was  a  rather  uncommon  feature  in  this  case  that  the  pain  was 
only  at  and  around  the  lower  end  of  the  sternum,  except  that 
occasionally  it  shot  along  the  sixth  intercostal  space.  The 
employment  of  Fowler's  solution  (in  doses  gradually  mounting 
to  twenty-one  minims  daily)  for  six  months  completely  eradi- 
cated the  anginal  tendency ;  the  proof  that  it  was  a  real  thei'a- 
peutic  effect  was  given  by  the  result  of  an  attempt  to  leave  the 
medicine  off  at  the  end  of  eight  weeks'  treatment ;  the  patient 
immediately  began  to  suffer  again.  When  she  really  left  off, 
at  the  end  of  six  months'  treatment,  she  had  had  no  tendency 
to  heart-pang  for  more  than  a  month,  and,  besides  this,  looked 
quite  another  creature  in  her  improved  vitality  and  vigor. 
Yet  the  menstrual  troubles  went  on,  and  the  function  was  not 
finally  suppressed  for  a  long  time  afterward. 

I  suspect,  however,  that  the  most  frequent  successes  with 
arsenic  will,  after  all,  be  made  in  the  cases  of  more  or  less 
anoemic  male  patients  who  are  attacked  with  the  neurotic 
fonn  of  angina  in  the  midst  of  a  career  (as  is  especially  the 
case  with  some  professional  careers)  that  implies  not  merely 
incessant  labor,  but  great  anxiety  of  mind.  The  drug  does 
little  good,  however,  if  not  positive  harm,  in  that  form  of 
angina  pectoris  minor  which  is  not  the  result  purely  of  these 
causes,  but  of  these,  or  some  of  these,  plus  the  morbid  action 
of  the  alcoholic  excess,  to  which  the  patient  has  fled  in  order 
to  relieve  mental  harassment  and  the  fatigue  that  comes  from 
overwork,  especially  overwork  at  tasks  that  are  not  congenial 
to  his  natural  disposition;  there  is  usually  in  such  cases  a 
heightened  irritability  of  the  alimentary  canal,  which  is 
almost  sure  to  cause  arsenic  to  disagree :  the  really  useful  treat- 
ment is  quinine  for  the  first  few  days,  and  then,  wlien  the 
stomach  muII  bear  it,  cod-liver  oil  in  increasing  doses,  up  to  a 
large  daily  amount  given  for  a  long  time  together. 


158  TREATMENT  OF  NEURALGIA. 

On  the  whole,  ai'senic,  from  its  singularly  happy  combina- 
tion of  powers  as  a  blood-tonic,  a  special  stimulant  of  the  ner- 
vous system,  and  withal  as  a  special  opposer  of  the  periodic 
tendency,  must  be  regarded  as  one  of  the  most  powerful 
weapons  in  the  physician's  hands,  and  (although  it  seems  to 
act  best  in  the  neuralgias  of  the  vagus  and  of  the  fifth)  there 
is  a  possibility  of  its  proving  the  most  effective  remedy  in 
almosti'any  given  case  vv  hich  may  come  before  us. 

2.  The  narcotic-stimulant  treatment  for  neuralgia  includes 
some  of  the  most  powerful  remedies  for  the  disease  which  we 
possess.  These  remedies  have  very  different  properties,  but 
they  all  agree  in  this,  that  in  small  doses  they  appear  resto- 
rative of  nei've-f  unction — in  large  doses  depressors  of  the  same. 

Four  very  different  types,  at  least,  of  narcotic-stimulant 
drugs  are  useful  in  neuralgia :  (a)  There  is  the  opium  type,  by 
which  ipSiin  is  very  directlj^  antagonized,  and,  besides  this, 
sleep  is  also  directly  favored.  (6)  There  is  the  belladonna 
type,  by  which  pain  is  also  much  relieved,  though  with  far 
greater  certainty  in  some  regions  than  in  others  (e.  g.,  much 
the  most  powerful  effect  is  seen  in  cases  of  pelvic  visceralgia), 
but  sleep  is  by  no  means  so  certainly  or  directly  produced  as 
by  opium,  (c)  There  is  the  chloral  type,  which  is  almost 
purely  hypnotic-  it  is  represented  almost  solely  by  chloral 
itself,  which  is  resembled  by  scarcely  any  other  drug,  (d) 
There  is  bromide  of  potassium,  which  stands  alone  for  its 
powerful  action  on  the  cerebral  vaso-motor  nerves,  and  which 
is  useful  in  neuralgia  simply  by  its  power  to  check  psychical 
excitement  directly  (through  the  circulation)  and  indirectly 
(through  the  production  of  sleep;. 

(a)  Opium  and  the  remedies  that  resemble  it  are,  for  the  treat- 
ment of  neuralgia,  fully  represented  by  the  hypodermic  use 
of  morphia,  which  is  the  only  kind  of  opiate  treatment  that 
ought  ever  to  be  employed,  save  in  very  exceptional  instan- 
ces. The  great  reasons  for  the  preferetice  of  the  subcutaneous 
administration  over  the  gastric  are,  the  economy  of  the  drug 
which  it  affects  and  the  much  smaller  degree  of  disturbance 
of  digestion  which  it  causes.  The  hypodermic  injection  of 
morphia,  if  conducted  on  correct  principles,  enables  us,  when 
necessary,  to  repeat  the  dose  a  great  number  of  times  with  but 
little  loss  of  the  effect,  and  consequently  with  a  much  smaller 
rate  of  progressive  increase  of  the  quantity  required ;  and  the 
absence  of  depressive  action  on  digestion  enables  us  to  carry 
out  simultaneously  that  plan  of  generous  nutrition  which  has 
already  been  shown  to  be  so  impoi^tant  a  part  of  treatment. 
Indeed,  the  case  is  hardly  expressed  with  sufficient  strength, 
when  we  say  that  hypodermic  morphia  is  usually  harmless  to 
the  digestive  functions ;  for  in  a  great  number  of  instances  it 
will  be  found  actually  to  give  an  important  stimulus  both  to 
appetite  and  digestion ;  and  the  patient,  who  without  its  aid 


TREATMENT  OF  NEURALGIA.  159 

could  hardly  be  persuaded  to  take  food  at  all,  will  not  unfre- 
quently  eat  a  hearty  meal  within,  half  an  hour  after  the  injec- 
tion. 

The  remarkable  effects  of  hypodermic  morphia  have,  how- 
ever, caused  it  to  be  rashly  and  indiscriminately  used,  and  so 
much  harm  has  been  done  in  this  way  tliat  it  is  necessary  to 
be  exceedingly  careful  in  the  rules  which  we  lay  down  for  its 
employment.  Upon  these  grounds  I  must  hope  to  be  excused 
if,  in  order  to  render  this  work  complete,  I  repeat  a  good  deal 
of  what  I  have  already  said  in  other  places.  In  the  first  place, 
I  shall  speak  of  the  mode  of  administration,  and  then  of  the 
dose. 

As  regards  the  mode  of  administration,  I  prefer  the  use  of  a 
solution  of  five  grains  of  acetate  of  moi^phia  to  the  drachm  of 
distilled  water;  if  the  acetate  be  a  good  specimen,  this  will 
dissolve  easily  (and  keep  some  time  without  precipitation) 
without  the  use  of  any  other  solvent.  With  a  solution  of 
this  strength  we  require  nothing  elaborate  in  the  form  of  the 
syringe;  a  simple  piston  arrangement  does  well;  only  it  is 
advisable  that  the  tube  shall  have  a  solid  steel  triangular 
point,  and  a  lateral  opening.  As  regards  the  place  of  injec- 
tion, I  must  repeat  the  opinion*  which  I  have  already  pub- 
lished, that  Mr.  Huntei''s  plan  of  injection  at  an  indifferent 
spot  is.  in  the  great  majority  of  instances,  fully  as  effective  as 
the  local  injection  would  be ;  nevertheless,  there  is  one  con- 
sideration which  in  some  cases  may  properly  induce  us  to 
adopt  the  latter  plan.  Very  nervous  and  fanciful  patients 
will  sometimes  be  much  more  readily  brought  to  allow  the 
operation  when  it  seems .  to  go  directly  to  the  affected  spot, 
when  they  would  be  sufficiently  incredulous  of  the  benefits  of 
an  injection  performed  at  a  distance  to  indulge  their  dislike  of 
incurring  pain  by  refusing  to  submit  to  it.  And  there  is  one 
class  of  cases  in  which  it  is  likely  that  there  are  real  physical 
advantages  in  the  local  injection ;  in  instances  of  old-standing 
neuralgia  with  development  of  excessively  tender  '"points," 
which  are  also  the  foci  of  the  severest  pain,  it  will*  sometimes 
be  advisable  to  inject  into  the  subcutaneous  tissue  at  these 
points.  There  is  undeniable  reason  for  thinking  that  the  sub- 
inflammatory  thickening  of  tissues  around  a  certain  point  of 
nerve  delays  the  transit  of  the  morphia  into  the  general  circu- 
lation (and  enables  it  to  act  more  directly  and  powerfully  on 
the  nerve,  which  it  thus  renders  insensitive  to  external  impres- 
sions ;  an  important  respite  is  thus  gained,  during  which  the 
nerve-centre  has  time  to  recover  itself  somewhat.  At  the 
same  time  it  must  be  remarked  that  this  immediate  injection 

*  In  a  paper  oa  the  "Hypodermic  Use  of  Remedies,"  in  the 
IracUtioner  of  July,  1868,  I  gave  tlie  reasons  for  this  opiaiou  in  full; 
and  I  see  no  reason  to  alter  any  thing  1  then  said. 


160  TREATMENT  OF  NEURALGIA. 

of  a  tender  point  is  apt  to  be  exceedingly  painful,  and  it  may 
be  absolutely  necessary  to  apply  ether-spray  before  using  the 
syringe.  In  early  stages  of  neuralgia,  before  the  formation  of 
distinct  tender  points,  there  is  no  advantage  whatever  (exce^ot 
the  indirect  one  above  mentioned)  in  the  local  injection.  And, 
on  the  other  hand,  it  is  often  of  great  consequence  not  to  run 
the  chance  of  disfiguring  such  a  part  as  the  face,  the  neck, 
etc. ,  when  the  injection  can  easily  be  done  over  the  deltoid,  or 
in  the  leg,  or  in  some  other  part  which  even  in  women  is 
habitually  covered  by  the  dress. 

The  dose  to  be  employed  is  an  exceedingly^  important 
matter,  and  one  as  to  which  practitioners  are  still  very  often 
injudicious.  We  ought  never  to  commience  with  a  larger  dose 
than  one-sixth  of  a  grain;  but  very  often  as  little  as  one- 
twelfth  of  a  grain  will  give  cftcctive  relief,  and  in  not  very  severe 
cases  it  is  well  worth  while  to  try  this  smaller  quantity. 
When  no  larger  quantity  than  one-sixth  of  a  grain  is  employed 
we  commonly  observe  no  narcotic  effects,  i.  e.,  there  is  no 
contraction  of  pupil,  no  heavy  stupor,  and,  although  the 
patient  very  often  falls  aslee^D,  on  waking  he  does  not  experi- 
ence headache,  nor  is  his  tongue  foul.  I  cannot  too  strongly 
express  the  opinion  that  it  is  advisible  by  all  means  to  content 
ourselves  with  this  degree  of  the  action  of  hypodermic  morphia, 
unless  it  fails  to  produce  a  decided  imx^ression  on  the  pain. 
But  in  very  severe  cases  our  small  doses  will  fail;  and  then, 
rather  than  allow  the  patient  to  continue  having  severe  par- 
oxysms unchecked,  we  must  frankly  admit  the  necessity  of 
using  a  narcotic  dose  froixi  one-quarter  to  one-half  of  a  grain, 
according  to  circumstances.  Whatever  actual  dose  be 
employed,  it  is  important  not  to  repeat  it  with  unnecessary  fre- 
quency;  once  a  day  in  the  mildei",  and  twice  a  day  in  the  more 
severe  cases,  will  be  all  that  is  advisible,  save  in  very  excep- 
tional cases :  the  point  being  to  administer  it  as  quickly  as  pos- 
sible after  the  commencement  of  an  exacerbation.  If  by  these 
means  we  can  prevent  the  patient  having  any  severe  pains 
during  a  period  of  several  days,  we  often  give  time  to  the 
affected  nerve  to  recover  itself  so  completely,  especially  with 
the  aid  of  other  measures  to  be  presently  mentioned,  that  the 
tendency  to  neuralgia  is  completely  broken  through,  and  we 
can  drop  the  injections,  either  at  once  or  by  rapid  diminution 
of  the  dose,  and  thereafter  treat  the  case  merely  with  tonics, 
and  witli  the  precautionary  measures  to  be  dwelt  upon  under 
the  headiiag  of  Prophylaxis.  But,  if  we  have  been  driven  to 
to  the  use  of  distinctly  narcotic  doses,  and  these  do  not  very 
speedily  break  the  chain  of  neuralgic  recurrence,  it  will  not  do 
to  continue  to  rely  upon  hypodermic  morphia ;  it  will  be  best  to 
try  some  of  the  local  remedies  (blistering,  galvanism)  with  it. 
If  this  combination  fails,  we  should  then  try  the  effect  of  atro- 
pine, the  sulphate  of  which,   hj'podei'mically  mjected,  fully 


TREATMENT  OF  NEURALGIA.  161 

represents  for  all  useful  purposes  the  mydriatic  class  of  nar- 
cotics . 

(6)  The  commencing-  hypodermic  dose  of  atropine  should  be 
one-one  hundred  and  twentieth  gram ;  it  is  not  often  that  so 
small  a  quantity  will  do  any  good,  but  it  is  necessary  to  use 
this  agent  with  great  precaution,  as  we  occasionally  meet  with 
subjects  in  whom  extremely  small  doses  provoke  most  uncom- 
fortable symi)toms  of  atropism,  as  dry  throat,  dilated  pupil, 
delirium,  and  scarlet  rash.  Commionly  we  shall  find  ourselves 
obliged  to  increase  the  dose  to  one-sixtieth,  one-fiftieth,  or  one- 
thirtieth  of  a  grain ;  and  in  a  very  few  cases  it  may  be  neces- 
sary to  go  even  as  high  as  the  one-sixteenth  or  one-twelfth. 
In  my  experience  such  instances  are  excessively  uncommon ; 
and  I  cannot  but  suppose  that  the  practitioners  who  use  the 
high  doses  frequently  must  inject  in  such  a  manner  as  to  fail 
to  get  the  whole  dose  taken  up.  [Absolutely  inexplicable  to 
me  is  the  statement  of  the  illustrious  Trousseau — that  hypo- 
dermic remedies  are  "less  active"  (!)  than  gastric  remedies — 
except  on  his  hypothesis.] 

The  most  remarkable  effects  that  I  have  seen  from  hypoder- 
mic atropia  were  obtained  in  cases  of  peri- uterine  neuralgia, 
especially  dysmenorrhceal  neuralgia.  Speaking  generally  of 
atropine,  it  must  undoubtedly  be  counted  far  inferior  to  mor- 
phia as  a  speedy  and  reliable  reliever  of  neuralgic  pain,  but  for 
all  pelvic  neuralgias  it  appears  to  me  on  the  whole  to  surpass 
morphia.  And  besides  this,  in  other  neuralgias,  where  opiates 
altogether  disagree  (as  with  some  subjects  they  do),  it  is  not 
uncommon  to  find  that  atropia  acts  with  exceptionally  good 
effect.  And  to  some  extent  I  am  inclined  to  confirm  Mr.  Hun- 
ter's opinion,  that,  where  atrojDia  does  stop  neuralgia,  it  does  so 
more  permanently  than  morphia. 

There  is  another  special  use'of  hypodermic  atropine  which  I 
have  not  seen  mentioned  by  any  one  but  myself,  but  which  is 
probably  very  important,  namely,  in  ophthalmic  neuralgia 
where  acute  iritis,  or  especially  glaucoma,  seems  coming  on. 
I  may  he  mistaken,  but  I  believe  that  in  three  cases  I  have  suc- 
ceeded, by  prompt  injection  of  sulphate  of  atropine  (one-sixtieth 
to  one-fortieth  of  a  grain),  in  saving  a  neuralgic  eye  from 
damage,  and  possibly  from  destruction,  from  impending 
glaucoma. 

(c)  The  class  of  cases  for  which  merely  hypnotic  remedies 
are  of  much  value  is  limited ;  nevertheless,  in  the  milder  kinds 
of  migraine  and  clavus,  especially  when  they  have  been  brought 
on  or  are  kept  up  by  mental  worry  or  hysterical  excitement, 
these  remedies  will  sometimes  prove  very  useful .  In  former 
days,  before  we  knew  chloral,  I  used  to  employ  camphor  for 
this  purpose ;  three  or  four  grains  being  administered  every  two 
hours:  and  in  hysteincal  hemicrania  of  a  not  very  severe  type 
this  not  unfrequently  produced  a  short  sleep,  fi-om  which  the 
11 


162  TREATMENT  OP  NEURALGIA. 

patient  awoke  free  from  the  pain.  But  chloral  infinitely  tran- 
scends in  value  any  agent  of  this  kind  that  was  known  before. 
Perfectly  valueless  for  the  really  severe  neuralgias,  it  is  of  the 
gi'eatest  possible  use  as  a  palliative  in  migraine  and  clavus, 
where  the  great  object,  for  the  moment,  is  to  get  the  patient  to 
sleep.  A  single  dose  of  twenty  to  thirty  grains  will  often 
effect  our  object :  it  may  be  repeated  in  two  hours  if  sleep  has 
not  been  induced ;  it  should  be  given  as  soon  as  the  pain  has  at 
all  decidedly  commenced. 

And  here  I  wish  to  make  some  special  remarks  on  the  sub- 
ject of  ' '  palliation, "  and  the  relation  it  bears  to  ' '  cure. "  Noth- 
ing is  more  common  than  to  read  serious  admonitions,  in 
medical  works,  about  the  folly  of  trusting  to  remedies  which 
only  palliate  for  the  moment,  but  leave  the  root  of  evil 
untouched ;  and,  of  course,  there  is  a  certain  respectable  modi- 
cum of  the  fire  of  truth  behind  all  this  orthodox  smoke.  In 
the  case  of  neuralgia,  however,  it  is  most  important  to  under- 
stand that  mere  i^alliation,  that  is,  stopping  of  the  pain  for  the 
moment,  may  be  either  most  useful  or  highly  injurious,  accord- 
ing to  the  way  in  which  it  is  done.  The  unnecessary  induc- 
tion of  narcosis  for  such  a  purpose,  doubtless,  is  most  repre- 
hensible ;  but  if  it  were  possible  simply  to  produce  sleep  from, 
which  the  patient  should  awake  refreshed,  Avithout  any  nar- 
cotic effects,  then,  certainly,  that  sort  of  palliation  must  be  good. 
That  is  precisely  what  the  judicious  use  of  chloral  does ;  and  I 
may  mention,  as  resembling  though  not  equalling  it,  the  action 
of  Indian  hemp,  which  has  been  particularly  recommended  by 
Dr.  Reynolds.  From  one-fourth  to  one-half  of  a  grain  of  good 
extract  of  cannabis,  repeated  in  two  hours  if  it  has  not  pro- 
duced sleep,  is  an  excellent  remedy  in  migraine  of  the  young. 
It  is  very  important,  in  this  disease,  that  the  habit  of  long 
neuralgic  paroxysms  should  not  be  set  up ;  and  if  the  first  two 
or  three  attacks  are  promptly  stopped,  by  the  mduction  of 
sound,  non-narcotic  sleep,  we  may  get  time  so  to  modify  the 
constitution,  by  tonics  and  genei'al  regimen  and  diet,  as  to 
eradicate  the  neuralgic  disposition,  or  at  least  reduce  it  to  a 
minimum.  But  I  would  decidedly  express  the  opinion  that 
such  remedies  as  either  opium  or  belladonna  are  mostly  unsuited 
to  this  purpose.  If  the  migraine  of  young  persons  does  not 
yield  to  chloral,  to  cannabis,  or  to  muriate  of  ammonia  (in 
twenty  or  thirty  grain  doses),  it  will  not  be  advisible  to  ply  the 
jiatient  with  any  remedies  of  the  narcotic-stimulant  class,  but 
to  trust  to  tonic  regimen  and  the  use  of  galvanisra. 

The  mention  of  muriate  of  ammonia,  which,  for  migraine 
and  clavus  and  the  milder  forms  of  sciatica,  not  unfrequently 
proves  useful  in  stopping  the  violence  of  a  paroxysm  and 
enabling  the  patient  to  get  some  refreshing  sleep,  leads  me  to 
noeice  that  not  only  may  a  variety  of  tlie  milder  narcotic- 
stimulants  be  employed  m  this  way,  but  the  external  stunulus 


TREATMENT  OF  NEURALGIA.  163 

of  heat  to  the  extremities  (very  hot  pediluvia)  greatly  assists 
the  action  of  any  such  remedies ;  especially  if  mustard-flour  be 
added,  so  that  a  mild  vapor  of  mustard  rises  with  the  steam 
and  is  inhaled.  Perhaps  the  ideal  medication,  to  arrest  a  had 
sick-headache,  is  to  give  twenty  grains  of  chloral,  and  make 
the  patient  plunge  his  feet  in  very  hot  mustard-and-water  and 
breathe  the  steam.  He  can  hardly  fail  to  fall  asleep  for  a 
longer  or  shorter  time,  and  awake  free  from.  pain. 

(d)  The  use  of  bromide  of  potassium  in  neuralgia  is  a  sub- 
ject of  great  importance,  and  which  requires  much  attention 
and  discrimination.  In  common  with,  I  dare  say,  many  others, 
I  made  extensive  trial  of  this  agent  when  it  first  began  to  be 
much  talked  of,  but  was  so  much  disappointed  with  its  effects 
in  neuralgias,  that  at  one  time  I  quite  discarded  it  in  the  treat- 
ment of  those  affections.  Renewed  experience  has  taught  me 
however,  that,  though  its  use  is  i-estricted,  it  is  extrem.ely 
effective  if  given  in  appropriate  cases  and  in  the  right  manner. 
For  tlii^  great  majority  of  neuralgias  it  is  quite  useless,  and, 
what  is  more,  proves  often  so  depi-essing  as  indirectly  to 
aggravate  the  susceptibility  of  the  nervous  system  to  pain. 
The  conditions,  sine  quis  non,  of  its  effective  employment  seem 
to  be  the  following :  The  general  nervous  power,  as  shown  by 
activity  of  intelligence,  and  capacity  of  muscular  exertion  and 
the  effective  performance  of  co-ordinated  movements,  must 
be  fairly  good,  find  the  circulation  must  be  of 
at  least  average  vigor ;  the  patient  must  not  have  entered  on 
the  period  of  tissue-degeneration.  Among  neuralgics  who 
answer  to  this  description,  those  who  will  benefit  by  the 
bromide  are  chiefly  subjects — especially  women— in  whom  a 
certain  restless  hyperactivity  of  mind  and  perhaps  of  body  also, 
seems  to  be  the  expression  of  Nature's  unconscious  resentment 
of  the  neglect  of  sexual  functions .  That  unhappy  class,  the 
young  men  and  young  women  of  high  principle  and  high 
mental  culture  to  whom  marriage  is  denied  by  Fate  till  long 
after  the  natural  i^eriod  for  it,  are  especial  sufferers  in  this  way 
and  for  them  the  bromide  appears  to  me  a  remedy  of  almost 
unique  power.  But  I  wish  it  to  be  clearly  understood  that  it  is 
not  to  the  sufferers  from  the  effects  of  masturbation  that  I 
think  the  remedy  specially  applicable :  on  the  contrary,  it  is 
rather  to  those  who  have  kept  themselves  free  from  this  vice, 
at  the  expense  of  a  perpetual  and  almost  fierce  activity  of  mind 
and  muscle.  The  effects  of  solitary  vice  are  a  trite  and  vulgar 
story ;  there  is  something  far  more  difficult  to  understand 
and  at  the  same  time  far  more  worth  understanding 
in  the  unconscious  struggles  of  the  organism  of  a  pure  minded 
person  with  the  tyranny  of  a  powerful  and  unsatisfied  sexual 
system .  It  is  in  such  cases,  which  it  needs  all  the  physician's 
tact  to  appreciate,  that  it  is  sometimes  possible  to  do  striking 
service  with  bromide  of  potassium ;  but  it  will  be   necessary  to 


164  TREATMENT  OF  NEURALGIA. 

accompany  the  treatment  with,  strict  orders  as  to  generous 
diet,  and,  very  likely,  with  the  administration  of  cod-liver 
oil. 

Having"  decided  that  bromide  of  potassium  is  the  proper 
remedy,  we  must  use  it  in  sufficient  doses.  Not  even  epilepsy 
itself  requires  more  decidedly  that  bromide,  to  be  useful,  shall 
be  given  in  large  doses.  It  is  right  to  commence  with  inoder- 
ate  ones  (ten  to  fifteen  grains),  because  we  can  never  tell, 
beforehand,  that  our  patient  is  not  one  of  those  peculiar  subjects 
in  whom  that  very  disagreeable  phenomenon — bromic  acne — 
will  follow  the  use  of  large  doses.  But  we  must  not  expect 
good  results  till  we  reach  something  like  ninety  grains  daily, 
let  me  add  that  it  is  not  so  far  as  I  know,  by  reducing  any 
' '  hypersesthesia"  of  the  external  genitals,  of  which  the  patient 
is  aware,  that  the  remedy  acts ;  I  have  not  seen  such  a  nexus 
of  disease  and  remedy  in  these  cases. 

3.  Local  Measures. — The  external  remedies  which  may  be 
applied  for  the  treatment  of  neuralgia  may  be  divided  into  (a) 
skin-stimulants  ;  (b)  paralyzers  of  peripheral  sensory  neiwes: 
(c)  remedies  adapted  to  diminish  local  congestion ;  {d)  remedies 
adapted  to  diminish  arterial  pulsation;  (e)  electricity;  (/) 
mechanical  means  of  protection. 

(a)  Among  the  skin-stimulants  blisters  hold  the  highest 
place  as  a  remedy  for  neui^algia ;  indeed  the  assertion  of  Val- 
leix,  that  they  are  the  best  of  all  remedies,  is  still  not  very  wide 
of  the  truth.  They  are  by  no  means  universally  applicable, 
and  the  degree  to  which  their  action  should  be  carried  varies 
materially  in  different  forms  of  the  disease,  but  they 
are  of  the  greatest  possible  service  in  a  large  number  of 
instances. 

It  is  possible  to  view  the  action  of  blisters  in  neuralgia  in 
more  than  one  Avay.  When  applied  in  such  a  manner  as  to 
vesicate  decidedly,  and  especially  if  kept  open  and  suppurating 
for  some  time,  they  cause  considerable  pain  of  a  difiPerent  kind 
from  that  of  neuralgia  itself  and  the  mental  effect  of  this, 
operating  as  a  diversion  of  the  patient's  thoughts  from  his 
original  trouble,  may  be  thought  to  assist  in  breaking  the  chain 
of  nervous  actions  by  which  he  is  made  to  feel  neuralgic  pain. 
There  may  be  something  in  this,  but  I  confess  that  I  do  not 
believe  this  kind  of  effect  goes  for  much  in  genuine  neuralgia. 
It  is  rather  in  the  pain  of  hypochondriasis,  and  the  so-called 
spinal  irritation  (to  be  described  in  the  second  part  of  this 
work),  that  such  an  action  of  blisters  proves  useful. 

Another  action  of  blisters,  which  some  authoj'S  hold  to  be 
perhaps  the  most  effective  portions  of  their  agency,  is  that 
which  is  produced  by  the  drain  of  fluid,  specially  when  they 
are  kept  open,  by  which  means  a  kind  of  depletion  is  set  up, 
and  the  morbid  irritation  that  causes  the  nerve  pain  removed. 
I  cannot  at  all  assent  to  this  view.     In  the  fii'st  place,  I  believe 


TREATMENT  OP  NEURALGIA.  165 

that  any  one  who  has  large  experience  of  blistering'  in  neural- 
gia will  ultimately  come,  as  Valleix  did,  to  believe  that  pro- 
longed drain  from  a  blister  is  rarely  or  never  useful,  and  that  a 
far  better  plan  is  that  of  so-called  flying  blisters,  renewed  at 
intervals  if  necessary.  The  most  genuine  successes  that  I  have 
procuz-ed  from  blistering  have  certainly  been  got  in  this  way. 
But  I  should  go  further,  and  say  that  the  prolonged  dram  and 
the  peculiar  kind  of  chronic  irritation  produced  by  a  suppura- 
ting blistered  surface  can  very  decidedly  aggravate  a  neuralgia; 
this  is  more  especially  the  case  when  the  blister  is  applied 
immediately  over  the  focus  pain. 

The  view  which  I  am  strongly  convmced  alone  explains  the 
beneficial  action  of  blisters  is  that  which  supposes  them  to 
act  as  true  stimulants  of  nerve-function.  In  order  that  this 
effect  shall  be  produced,  it  will  be  necessary  that  the  skin-irri- 
tation be  either  produced  at  some  distance  from  the  seat  of  the 
greatest  pain,  or  that,  if  applied  in  that  spot,  it  shall  be  compara- 
tively mild  in  degree.  And  accordingly,  I  have  been  led,  in  my 
observations  to  apply  the  blister  at  some  distance  from  the 
focus  of  pain.  An  indifferent  point,  however,  will  not  do — 
there  must  be  an  intelligible  channel  of  nervous  communica- 
tion between  the  irritated  portion  of  skin  and  the  painful  nerve. 
This  object  is  accomplished  by  placing  the  blister  as  close  as 
may  be  to  the  intervertebral  foramen  from  which  the  painful 
nerve  issues ;  the  effect  of  this  is  xorobably  a  stimulation  of  the 
superficial  posterior  branches,  which  is  carried  inward  to  the 
central  nucleus  of  the  nerve.  I  must  say  that  the  results 
which  I  have  derived  from  this  plan  of  treatment  have  been  far 
more  satisfactory  than  those  which  I  used  to  obtain  when  I  habit 
ually  applied  the  vesication  as  near  as  might  be  to  the  focus  of 
peripheral  pain ;  and  I  think  that  this  result  tallies  well  with  the 
idea  that  the  essential  mischief  in  neuralgia  consists  in  an  enfee- 
bled vitality  of  the  central  end  of  the  posterior  root.  An  ex- 
ceedingly interesting  conflrmation  of  this  idea  as  to  its  modus 
operandi  has  been  afforded  me  by  the  fact  that  not  merely 
neuralgic  pain,  but  also  trophic  and  inflammatory  complica- 
tions attending  it,  have  been  sensibly  relieved,  in  several  cases 
that  I  have  seen,  by  this  mode  of  reflex  stimulation.  This  has 
been  particularly  the  case  in  herpes  zoster,  where  the  process  of 
inflammation  and  vesiculation  has  been  very  promptly  checked 
by  the  application  of  a  tolerably  powerful  blister  by  the  side  of 
the  spine  at  the  proi^er  level ;  and  I  am  gratified  to  mention  that 
Dr.  J.  K.  Spender,  of  Bath,  pointed  out  this  fact  *  at  a  time 
when  he  had  only  seen  my  statement  that  the  pain  could  be 
relieved  in  this  way.  In  the  case  of  the  trigeminus,  the  same 
kind  of  reflex  stimulation  is  most  effectively  obtained  by  apply- 
ing the  blister  over  the  branches  of  the  cervico-occipital,  at  the 

Practitiouei;,  vol.  iv. 


166  TREATMENT  OF  NEIJRALGIA. 

nape  of  the  neck ;  and  it  is  remarkable  what  powerful  effects 
are  sometimes  thtis  iDroduced,  even  in  cases  that  wear  the  most 
nni)romising  aspect.  For  example,  in  the  desperate  epilepti- 
form tic  of  old  age,  I  have  more  than  once  seen  a  complete 
cessation  of  suffering,  which  lasted  for  a  very  long  tim.e — so 
long,  in  fact,  as  to  make  me  hope  against  hope  that  it  mis'ht 
never  return.  I  do  not  now  entertain  any  such  expectations 
from  this  remedy ;  still,  its  value  is  very  great. 

There  are  curious  diiferences  between  the  effects  of  blister- 
ing in  trigeminal  or  intercostal  neuralgia  and  in  sciatica.  On 
the  whole,  it  Vv'ould  appear  that  blistering  m  the  neighborhood 
of  the  spine  is  less  frequently  effective  in  the  latter,  and  we 
sometimes,  after  failing  with  this  method,  obtain  immediate 
success  by  tv/o  or  three  repetitions  of  the  flying  blister,  some- 
where over  the  trunk  of  the  nerve,  especially  just  outside  the 
sciatic  notch.  I  have  one  lady  patient  in  whom  this  series  of 
phenomena  has  several  times  been  observed ;  and  I  have  seen 
it  occur  in  a  particular  attack,  in  other  patients,  in  ^vhoin, 
nevertheless,  on  another  occasion  the  spinal  blistering  has 
been  promptly  effective. 

I  consider  blistering  of  the  posterior  branches  to  be  an 
important,  and  usually  an  essential,  element  in  the  treatment 
of  all  cases  of  sciatica  in  the  middle  period  of  life  which  have 
reached  some  severity  and  lasted  long  enough  to  become  com- 
phcated  with  decided  secondary  affections. 

In  all  cases  whei-e  blistering  is  employed  it  is  advisable  to 
adopt  the  simultaneous  use  of  hj^iDodermic  morphia  or  atropine ; 
this  combination  of  remedies  is  exceedingly  powerful. 

Lastly,  it  must  be  said  of  blistering,  that,  on  the  whole,  it  is 
a  remedy  not  well  fitted  to  be  applied  to  aged  subjects ;  and  in 
its  seA^erer  forms  it  should  never  be  applied  to  patients  who 
are  greatly  prostrated  in  strength.  For  it  must  be  borne  in 
mind  that  the  remedy  may  miss  its  aim  of  relieving  the  neu- 
ralgia, in  which  case  it  is  necessaiy  to  remember,  more  accu- 
rately than  many  practitioners  appear  to  do,  what  a  very 
serious  element  of  misery  and  prostration  will  be  introduced 
into  the  case  by  the  vesication  itself. 

I  am  not  convinced  that  any  of  the  other  forms  of  severe 
skin-irritation  (e,  gr.,  tartar-emetic  munction,  or  the  use  of 
veratrine-oiiitment  to  such  a  degree  as  to  produce  not  the 
anaesthetic  but  the  irritant  effects)  are  of  any  particular  value ; 
if  blistering  failed,  I  should  not  expect  to  see  them  succeed. 

A  milder  degree  of  skin-stimulation  is  represented  by  rube- 
facient liniments  of  various .  kinds,  which  may  be  briskly 
rubbed  into  the  skin  along  the  track  of  the  painful  nerve, 
without  any  danger  of  producing  vesication.  Among  this 
class  I  continue  to  prefer  chloroform  diluted,  with  six  or  seven 
parts  of  chloroform,  to  any  other ;  in  the  milder  forms  of  neu- 
ralgia, especially  in  young  persons  and  first  attacks,  it  is  sur- 


TREATMENT  OF  NEURALGIA.  167 

prising-  how  frequently  tne  paroxysm  may  be  greatly  relieved, 
if  not  arrested.  Still,  this  can  only  be  regarded  as  the  merest 
palliative ;  and  in  severer  cases  snch  aiDplications  are  useless. 
Occasionally,  when  chloroform-liniment  has  failed,  a  mustard 
plaster  will  do  good. 

The  mildest  degree  of  skin-stimulation  is  represented  by  the 
continuous  application  of  moist  warmth,  which  is  best  effected 
by  the  simple  application  of  moistened  spongio-piline ;  so  far 
as  I  have  observed,  however,  it  is  rather  in  cases  of  myalgia 
than  in  true  neuralgia  that  this  does  good ;  in  the  latter  it  is 
probably  little  more  than  a  mere  protector  against  cold. 

(6)  A  variety  of  agents  can  be  employed  with  the  object  of 
temporarily  interrupting-  the  conductivity  of  the  painful  nerve ; 
by  this  means  a  period  of  rest  is  obtained  during  which  the 
centres — sensory  and  psychial — have  timie  to  regain  a  juster 
equilibrium,  and  the  habit  of  pain  is,  %,to  tanto,  broken 
through. 

There  is  one  agent  of  this  class  which  for  general  purposes  I 
do  not  think  is  worth  retaining-  on  our  list  of  sensory  paralyses 
— namely,  cold.  Cold,  to  be  of  any  value,  ought  to  be  of  the 
degree  which  is  represented  by  ice  allowed  to  melt  slowly  in 
contact  with  the  skin ;  and  for  the  majority  of  neuralgias  this 
is  decidedly  inferior  to  other  remedies  that  can  be  applied  by 
painting  or  inunction.  The  one  case  in  which  ice  is  supremely 
useful  is  in  neuralgia  of  the  testis;  here  I  make  no  doubt  that 
it  is  almost,  if  not  quite,  the  most  useful  remedy  we  can 
employ,  although  of  course  other  means  must  be  taken  to 
modify  the  neuralgic  temperament.  It  should  be  applied  the 
m.oment  an  attack  comes  on. 

Far  more  useful,  in  neuralgias  generally,  is  the  external 
application  of  aconite  or  of  veratrine.  Aconite  may  be 
employed  in  the  milder  or  the  stronger  form ;  in  the  former 
case,  we  simply  paint  the  ordinary  tincture  on  the  skin  over 
the  painful  nerves  (avoiding  any  cracks  or  sores) ;  in  the  latter, 
we  rub  in  an  ointment  containing  one  grain  of  the  best  hydrate 
of  aconitine  to  the  drachm  of  lard,  about  twice  a  day,  and  to 
such  an  extent  as  to  maintain  complete  numbness  of  the  parts 
continuously,  for  two,  three,  or  four  days  I  do  not  believe 
that  this  will  ever,  by  itself,  cure  a  true  neuralgia  of  any  con- 
siderable severity ;  but  I  have  more  than  once  known  its  inter- 
vention, at  a  crisis  in  treatment  Avhen  it  seemed  that  other 
remedies  might  fail,  produce  a  striking  change  in  the  progress 
even  of  a  very  bad  case. 

A  milder,  but  still  very  useful  form  of  the  same  kind  of 
action,  is  produced  by  veratrine-ointment.  I  would  recom- 
mend, however,  as  a  rixle,  that  it  be  employed,  at  any  rate  at 
first,  of  weaker  strength  than  that  recommended  in  the  Phar- 
macopoeia, for  with  some  persons  it  is  easy  to  pass  the  anaes- 
thetic, and  to  enter  on  the  irritant,  action  of  veratrine  upon 


168  TREATMENT  OF  NEURALGIA. 

the  skin.  This  leads  me  to  give  a  caution  that  should  properly 
have  come  earlier,  when  I  was  speaking  of  skin-stimulants.  In 
aged  subjects,  especially,  we  rather  frequently  meet,  in  neu- 
ralgia, with  a  specially  irritable  state  of  the  skin,  even  although 
there  may  be  at  the  same  time  some  loss  of  common  and  tactile 
sensation ;  and  the  practitioner  must  be  warned  against  the 
danger  of  producing  an  amount  of  skin-irritation  which  will 
fearfully  annoy  his  patient.  I  speak  feelingly,  having  by 
such  an  indiscretion  lost  the  richest  patient  who  ever  favored 
my  consulting-room  with  his  presence ! 

The  inunction  of  mild  veratrine-ointment  is  extremely  use- 
ful, as  an  adjunct  to  other  treatment,  in  migraine  and  supra- 
orbital neuralgias  of  suckling  Avomen,  and  of  chlorotic  girls. 
I  have  also  seen  it  do  much  good  in  mammary  neuralgia. 

The  last  division  of  the  subject  of  paralyzing  agents  in  the 
treatment  of  neuralgia  includes  the  sui'gical  operations  for 
division  or  resection  of  a  pahiful  nerve.  Upon  this  question 
there  is  much  difficulty  in  speaking  decidedly,  i  admit  at 
once,  of  course,  that  surgical  interference  is  evidently  indi- 
cated when,  along  with  decided  and  intractable  neui'algic  pain, 
there  is  plain  evidence  either  of  the  existence  of  a  neuromat- 
ous tumor,  or  the  presence  of  a  foreign  body  impacted,  or  a 
tight  cicatrix  pressing  ux^on  a  nerve.  I  admit,  also,  though 
with  much  greater  qualifications,  that  carious  teeth  may  need  to 
be  extracted  before  we  can  cure  a  neuralgia ;  but  even  here  I 
should  put  in  the  decided  caveat  that  we  must  consider  whether 
the  system  is  in  a  state  to  bear  the  shock,  and  that  in  any  case 
we  probably  ought  to  mitigate  the  effects  of  the  operation  by 
performing  it  under  chloroform.  And  I  need  hardly  tell  any 
one,  who  is  familiar,  either  practically  or  from  reading,  with 
the  subject,  that  thousands  of  cariou;^  teeth  have  been 
extracted  from  the  mouths  of  neuralgic  patients,  not  only  with- 
out benefit,  but  with  the  effect  of  distinctly  aggravating  the 
disease.  Aiid  I  am  yet  more  doubtful  as  to  the  advisability  of 
such  surgical  procedures  as  the  division  or  the  resection  of  a 
piece  of  the  painful  nerve.  Theoretically,  as  the  reader  will 
understand  from  the  strong  opinion  I  have  given  as  to  the 
mainly  central  origin  of  neuralgias,  I  never  could  anticipate 
that  such  a  procedure  would  be  more  than  temporarily  suc- 
cessful ;  on  the  contrary,  the  mischief  in  the  central  end  of  the 
nerve  remaining,  I  should  suppose  that  the  trying  process  of 
the  reunion  of  the  nerve  (which  always  takes  place)  would  be 
almost  certainly  attended  with  a  revival  of  tlie  neiiralgia,  too 
probably  in  an  aggravated  form.  The  only  two  cases  of 
excision  of  a  piece  of  the  nerve,  that  I  have  ever  seen,  com- 
pletely answered  to  this  anticipation.  In  common  fairness, 
however,  I  must  admit  that  there  is  a  large  amount  of  e\d- 
dence  on  the  other  side.  Neuralgias  of  the  trigeminus  are 
pretty  neai'ly  the  only  cases  in  which  the  proposal  of  neu- 


TREATMENT  OF  NEURALGIA.  169 

rotomy  or  neurectomy  ought  to  be  entertained;  in  mixed 
nerves  the  inconvenience  of  the  muscular  paralyses  that  would 
follow  would  be  usually  too  serious  to  allow  of  our  incurring 
them.  But  resection  of  painful  branches  of  the  trigeminus 
has  been  performed  in  a  great  number  of  instances,  more 
especially  by  German  surgeons,  with  results  tliat  merit  our 
attention ;  the  cases  recorded  by  Nussbaum,  Wagner,  Bruns, 
and  Podratzki,  may  be  especially  referred  to.  On  the  other 
hand,  with  the  exception  of  simple  division  of  the  nerve, 
which  can  be  subcutaneously  performed,  and  is  a  trivial  pro- 
ceeding (but  has  very  short-lived  effects),  these  operations  are 
by  no  means  without  danger,  especially  when  they  are  pushed 
to  such  a  lengtli  as  the  opening  of  bony  canals,  and  the 
resection  of  considerable  portions  of  bone  in  order  to  get  suffi- 
ciently far  toward  the  centre,  and  fatal  results  have  in  more 
than  one  case  followed.  Above  all,  we  can  never  too  seriously 
reflect  on  the  most  interesting  case  of  Niemeyer's  reported  by 
Wiesner,*  in  which  the  most  formidable  operations  of  this 
kind  have  been  performed,  in  an  apparently  despei'ate  case  of 
epileptiform  facial  tic,  and  in  which,  after  all,  the  application 
of  the  constant  current  painlessly  effected  an  infinitely  greater 
amount  of  good  than  had  been  done  by  all  those  severe  and 
painful  surgical  manipulations.  I  think  it  is  impossible,  after 
this,  not  to  conclude  that  neurectomy  ought  never  to  be  even 
thought  of  except  as  a  last  resort,  in  cases  of  extreme  severity, 
after  other  measures  had  been  patiently  tried  and  had 
decisively  failed. 

(c)  Of  remedies  that  are  intended  to  relieve  local  congestion, 
I  must  speak  with  very  doubtful  approbation.  Leeches  or 
scarifications  are,  I  think,  very  seldom  of  value.  The  only 
remedy  that  has  sometimes  seemed  to  do  good  is  local  com- 
pression, and,  after  all,  it  is  quite  as  likely  that  this  acts  by 
anae,st]ietizmg  the  nerve  as  by  reducing  congestion. 

(d)  Remedies  that  intefere  mechanically  with  arterial  pulsa- 
tion are  of  considerable  value  where  they  can  be  effectively 
applied.  I  have  already  pointed  out  the  specially  aggravating 
effect  of  the  momentarily-repeated  shocks  of  arterial  ])ulsation 
upon  neuralgic  pain.  Where,  then,  it  is  possible,  effectively 
to  control  an  artery  pretty  near  to  the  point  where  it  divides 
into  the  branches  that  lie  close  to  the  painful  part  of  the  nerve, 
it  is  always  worth  while  to  try  the  experiment.  But  such  a 
measure  as  the  compression  of  the  carotid  in  trigeminal  neu- 
ralgia is  of  very  doubtful  propriety ;  I  suspect  the  consequent 
ana^miation  of  the  brain  more  than  does  away  with  any  bene- 
fit that  might  be  mechanically  produced,  And  any  attempt 
to  intefere  with  the  general  arterial  circulation  by  cardiac 
depressants  is  not  to  be  permitted  for  an  instant. 

*  Berlin,  kliu.  Wochenscli.,  17,  1868. 


170  TREATMENT  OF  NEURALGIA, 

(e)  We  enter  now  upon  a  most  important  subject,  the  treat- 
ment 'of  neuralgia  by  electricity.  It  is  necessrry  to  exercise 
much  caution  in  speaking  upon  this  topic,  and,  as  I  shall  have 
to  express  somewhat  decided  opinions,  I  may  be  excused  for 
referring  to  the  circumstances  under  which  I  have  arrived  at 
my  present  stand-point  iipon  this  question.  I  can  hardly  be 
accused  of  having,  with  any  very  rash  haste,  espoused"  the 
cause  of  medical  electricity  in  the  therapeutics  of  pain,  as  any 
one  will  see  who  cares  to  turn  to  my  article  on  Neuralgia* 
written  only  three  years  ago.  At  that  time  I  had  already  been 
studying  the  subject  for  a  considerable  period,  but  was  so  con- 
vinced of  the  miiltitude  of  opportunities  for  fallacy  that  beset 
the  student  of  electro-therapeutics,  that  I  was  unwilling  to 
state  more  than  the  minimum  of  what  I  hoped  and  believed 
might  be  afl'ected  by  this  mode  of  treatment.  Since  that  time 
I  have  become  more  fully  acquainted  with  the  researches  of 
foreign  observers,  and,  with  the  help  of  their  indications,  have 
been  able  to  apply  mj'self  more  fruitfully  to  my  personal 
inquiries  into  the  matter-  The  result  is,  that  I  am  now  able  to 
speak  with  far  gi'eater  assurance  of  the  positive  value  of  elec- 
tricity as  a  remedy  for  neuralgic  pain.  I  shall  make  bold  to 
say  that  nothing  but  the  general  ignorance  of  the  facts  can  ac- 
count for  the  extraordinary  supineness  of  the  mass  of  English 
practicioners  Avith  regard  to  this  question. 

In  the  first  place,  I  have  arrived  at  a  decided  conviction  that 
Faradic  electricity  is  of  little  or  no  value  in  true  neuralgias, 
and  that  the  cases  which  are  apparently  much  benefited  by  it 
will  invariably  be  found,  on  more  cai'eful  investigation,  to 
belong  to  some  other  category. 

On  the  efi'ect  of  frictional  electricity  I  have  had  such  very 
small  experience  that  I  cannot  venture  to  speak  with  any  con- 
fidence, and  the  accounts  that  I  have  heaixl  from  others  whose 
experience  is  much  larger  have  not  led  me  to  attribute 
much  importance  to  this  agent.  If  I  am  to  judge  at  all,  I 
should  say  it  merely  acts  as  a  skin-stimulant,  and  is,  hi  that 
capacity,  inferior  to  many  other  simpler  and  more  facile 
applications. 

Very  difrerent  is  the  verdict  of  experience  as  regards  the 
eiTects  of  the  constant  current;  here  the  results  which  I  have 
obtained  have  been  so  remarkable  that  even  now  I  should  dis- 
trust their  accuracy,  were  it  not  that  they  are  in  accord  with 
the  general  result  which  (among  minor  discrepancies)  may  be 
gathered,  we  may  fairly  say,  from  all  the  more  important 
researches  that  have  lately  been  carried  out  in  Germany.  The 
constant  current,  as  I  now  estimate  it,  is  a  remedy  for  neural- 
gia unapproached  in  power  by  anj'  other,  save  only  blistering 
and  hypodermic  morphia,  and  even  the  latter  is  often  sur- 

*  "  System  of  Medicine,"  vol.  ii. 


TREATMENT  OF  NEURALGIA.  171 

passed  by  it  in  permanence  of  afPect;  while  it  is  also  applic- 
able in  not  a  few  cases  where  blistermg  would  be  useless  or 
worse. 

The  English  medical  profession  has  not  as  yet  adequately 
appreciated  the  necessity  for  great  care  in  the  clioice  of  appa- 
ratus and  the  mode  of  application  of  electricity.  It  is  all- 
important,  however,  and  especially  in  the  case  of  applying 
galvanism  for  the  relief  of  pain.  The  first  quality  that  must 
be  absolutely  required  in  a  battery,  that  is  to  be  used  for  this 
purpose,  is  that  it  shall  deliver  its  current  with  as  little  as  jdos- 
sible  variation  of  tension,  in  fact  that  it  shall  be  constant, 
and  not  merely  continuous ;  a  vast  majority  of  all  the  various 
galvanic  apparatus  that  have  been  used  have  been  merely  the 
latter,  and  have  consequently  been  almost  valueless  for  the 
relief  of  pain.  Such  are  Pulvermacher  s  chains,  the  voltaic 
piles  made  with  elements  of  metallic  gauze,  Cruickshank's 
battery,  and  many  others  that  have  been  used.  A  sufficiently 
constant  current  may  be  obtained  from  either  of  the  following 
apparatuses.  (1)  Daniell's  battery,  (2)  Bunsen's,  (4)  Smee's, 
For  hospital  use,  the  Daniell  battery  (in  Muirhead's  modifica- 
tion, or  with  the  form  of  cells  introduced  by  Siemen's-Halske) 
is  perhaps  the  most  desirable ;  but  for  -^jrivate  x^ractice  it  is 
worth  while  to  sacrifice  something  of  the  suiDerior  constancy 
which  we  gain  in  the  Daniell  battery  for  the  sake  of  compara- 
tive portability.  All  purposes  which  we  aim  at  in  the  elec- 
tric treatment  of  neuralgia  may  be  sufficiently  obtained  by  the 
use  either  of  the  Bunsen  battery  (zinc-carbon,  excited  by 
dilute  sulphuric  acid),  as  modified  by  Stohrer,  or  by  the  Smee 
battery  (zinc  and  platinized  silver,  excited  by  dilute  sulphuric 
acid),  as  in  the  highly  convenient  apparatus  devised  by  Mr. 
Foveaux,  of  Weiss  &  Son's.  It  must  be  remarked  that,  for 
the  purpose  of  treating  neuralgia,  we  shall  never  need  to 
employ  more  than  fifteen,  or  at  the  utmost  twenty,  cells  of 
either  of  these  batteries.  Both  the  Stohrer's  Bunsen  and  the 
modified  Smee  of  Weiss  are  made  so  that  the  elements  are  not 
immersed  in  the  exciting  fluid  until  the  moment  when  the 
battery  is  going  to  be  used;  a  simple  mechanism  at  once 
throws  the  battery  into  or  out  of  gear.  In  this  way,  destruc- 
tion of  the  elements  is  minimized ;  and  either  of  these  two  bat- 
teries may  be  used  for  from  three  to  six  months  without  any 
renewal,  supposing  the  average  work  done  to  be  one  or  two 
daily  seances .  if  the  battery  is  worked  harder,  it  will  require 
more  frequent  revivification.  I  strongly  recommend  London 
practitioners  to  deliver  themselves  from  all  care  and  trouble 
about  the  repair  of  their  batteries,  by  making  an  agreement 
with  the  manufacturers  to  inspect  and  set  them  in  order  at 
stated  intervals.  The  country  practitioiier,  on  the  other  hand, 
will  do  well  to  familiarize  himself  with  the  process  of  renew- 
ing  the   acid,   of  cleaning   the   plates,    of  amalgamating  the 


172  TREATMENT  OF  NEURALGIA. 

zinc,  etc. ;  in  fact,  to  make  himself  independent  of  tlie  manu- 
facturer in  every  thing  short  of  an  actual  renewal  of  the  ele- 
ments, when  that  becomes  necessary.  For  all  further  details 
respecting  the  above-named,  and  other  batteries,  I  must  refer 
the  reader  to  systematic  works  on  medical  electricity.*  I  must 
now  pass  on  to  the  various  modes  of  application,  and  the  cau- 
tions to  be  observed. 

It  is,  in  the  first  place,  necessary  to  say,  that  all  the  best 
observers  coincide  in  the  statement  that  the  use  of  a  current 
intense  enough  to  produce  actual  pain  or  severe  discomfort  is 
never  to  be  thought  of  in  the  treatment  of  true  neur-algias ; 
such  practice  will  infallibly  do  harm.  Only  such  a  current  is 
to  be  employed  as  produces  merely  a  slight  tingling,  and  (on 
jjii  longed  application)  a  slight  burning  sensation,  with  a  little 
reddening  of  the  skin  at  tlie  negative  electrode.  This  being 
the  case,  it  is  perhaps  not  unnatural  for  those  who  have  not 
had  practical  experience,  to  suspect  that  an  application  which 
causes  so  little  palpable  perturbation  is  devoid  of  any  positive 
inliuence  at  all.  Such  skepticism  will  certainly  not  survive 
any  tolei'ably  lengthened  observation  of  the  actual  facts ;  but, 
as  some  persons  may  be  deterred  by  this  priina-facie  view  of 
the  case  from  ixiaking  any  fair  trial  of  the  current,  it  may  be 
worth  while,  here,  to  allude  to  the  unmistakable  physical 
effects  which  similarly  painless  constant  currents  are  repeat- 
edly observed  to  produce  in  cases  of  motor-paralysis  attended 
with  a  wasted  condition  of  muscles.  Those  who  have  had 
experience  oi  the  treatment  of  such  cases  know  that  it  is  a  by 
no  means  infrequent  thing  to  see  both  muscles  and  nerves 
aroused  from  a  state  of  complete  torpidity,  and  brought  into  a 
condition  in  which  the  Faradic  current,  quite  powerless  before, 
is  again  able  to  excite  powerful  contractions,  while,  at  the 
same  time,  the  bulk  of  the  muscles  has  increased  most  sensi- 
bly. These,  surely,  are  sufficient  indications  of  a  positive 
action  of  the  painless  constant  current ;  and  such  facts  have 
now  been  recorded,  in  multitudes,  by  most  competent  observers. 

The  next  maxim  of  first-rate  importance  is  that  the  applica- 
tions of  the  current  should  be  made  at  regular  intervals,  and 
at  least  oiice  daily ;  in  most  instances,  this  is  enough,  but  occa- 
sionally it  will  be  found  useful  to  operate  twice  in  the  day. 
The  matter  of  regularity  is,  I  find,  of  great  consequence,  and 
it  will  not  do  to  intermit  the  galvanism  immediately  on  the 
occurrence  of  a  break  in  the  neuralgic  attacks :  it  should  be 
continued  for  some  days  longer. 

The  length  of  sittings  is  a  point  as  to  which  there  is  _  consid- 
erable difference  of  opinion  between  various  authorities ;  but 

*  Tlie  English  reader  may  consult  Altliaus  ("A  Treatise  on  Medi- 
cal Electricity,"  second  edition,  Longmans),  or  Meyer  ('"Medical 
Electricity,"  translated  by  Hammond:  Trubner  &  Co.) 


TREATMENT  OF  NEURALGIA.  173 

my  own  experience  coincides  witli  that  of  Eulenbiirg-,  that 
form  five  to  ten,  or,  at  the  utmost,  fifteen  minutes,  is  almost 
the  range  of  time. 

Closely  connected  with  the  question  of  the  length  of  sittings, 
is  that  of  the  continuity  with  which  the  current  is  to  be 
applied.  I  have  seen  the  best  results,  on  the  whole,  from 
passing  a  weak  current,  wtthout  any  breaks,  for  about  five 
minutes.  But,  where  there  are  several  foci  of  intense  pain, 
it  will  often  be  advisable  to  apply  the  current  to  each  of- these, 
successively,  for  three  or  four  minutes . 

The  places  to  which  the  electrodes  should  be  applied  vary 
much  according  to  the  nature  of  the  case. 

Benedikt's  rule,  that  the  application  of  electricity,  to  be  use- 
ful, must  be  made  to  the  seat  of  the  disease,  is  undoubtedly 
true ;  but  it  is  capable  of  being  applied  in  a  somewhat  differ- 
ent manner  from  that  which  he  recommends  in  particular 
cases,  the  difference  being  due  to  the  view  of  the  pathology  of 
neuralgia  which  is  taken  in  this  work.  That  view  is,  that  the 
essential  locus  morbi  is  always  in  the  posterior  nerve-root  (and 
usually  in  that  portion  of  the  root  which  is  within  the  sub- 
stance of  the  cord),  and  that  the  perijjheral  source  of  irrita- 
tion, if  any,  is  only  of  secondary — though  sometimes  of  con- 
siderable— importance.  Hence  the  main  object,  in  electriza- 
tion, would  seem  to  be  to  direct  the  influence  of  the  current 
upon  the  posterior  nerve-root.  This  may,  however,  be  done 
in  different  ways,  according  to  the  situations  in  which  we 
place  the  electrodes,  and  the  direction  in  which  we  send  the 
current. 

There  are,  as  yet,  very  considerable  differences  of  opinion 
among  electro-therapeutists  as  to  the  principles  which  should 
govern  us,  both  in  the  localization  of  the  effect  and  the  direc- 
tion of  the  current.  Benedikt,  for  example,  recommends  that 
the  current  should  be  directed  toward  the  supposed  seat  of  the 
mischief.  Thus,  if  we  suppose  a  neuralgia  to  depend  on  mor- 
bid action  within  the  spinal  cord,  then  we  may  galvanize  the 
spine,  taking  care  to  make  the  current  come  out  through  any 
vertebra  over  which  we  detect  tenderness.  If  we  suppose  the 
seat  of  the  disease  to  be  in  the  nerve-root  in  the  mere  oi'di- 
nary  sense  of  the  word,  then  we  apply  the  positive  pole  to  the 
vertebra  opposite  the  highest  nerve-origin  that  can  be  con- 
cerned, and  we  stroke  the  negative  pole  down  by  the  side  of 
the  spinous  processes,  some  forty  times  in  succession.  The 
proportion  of  cases  of  idiopathic  neuralgia  in  which  this 
treatment  succeeds  is,  according  to  Benedikt,  very  large.  In 
other  cases,  he  sends  the  current  from  the  cord  to  the  apparent 
seat  of  pain. 

On  the  other  hand,   Althaus*  tells  us  that,  whether  the 

*  "  A  Treatise  on  Medical  Electricity,"  second  edition,  Longmans. 


174  TREATMENT  OF  NEURALGIA. 

application  be  central  or  peripheral,  it  is  the  positive  pole, 
alone,  which  should  be  applied  to  the  part  which  we  intend  to 
affect:  and  that  the  application  of  the  negative  pole  in  this 
situation  is  rather  likely  to  do  harm  than  good,  as  proving  too 
exciting.  Eulenburg,  also,  says  that  in  general  the  positive  pole 
should  be  applied  to  the  seat  of  the  disease,  the  negative  on  an 
indifferent  spot,  or  on  the  peripheral  distribution  of  the  nerve. 

It  is,  however,  very  doubtful  to  me  whether,  in  the  majority 
of  cases,  the  direction  of  the  current  makes  any  considerable 
difference  in  its  effects,  provided  only  that  the  stream  is  fairly 
directed  so  as  to  include  the  in  the  locus  7norbi  circuit,  and  care 
is  taken  to  apply  it  with  sufficient  persistence  and  with  not  too 
great  intensity.  Upon  this  point  I  am  glad  to  be  able  to  cite 
the  authority  of  Dr.  Reynolds,  whose  experience  is  very  large. 
This  author,  while  admitting  that  in  theory  the  "  direct  "  and 
the  ' '  inverse "  currents  would  seem  likely  to  have  different 
effects,  declares  that  in  practice  this  does  not  prove  to  be  the 
case,  either  in  the  instance  of  pain  of  nerve  or  of  spasm 
of  muscle.  Dr.  Buzzard,  also,  in  relating  a  very  strik- 
ing case  (which  I  had  the  advantage  of  personally  observing) 
before  the  Clinical  Society,  particularly  mentioned  that  the 
direct  and  the  inverse  currents  had  a  precisely  similar  effect  in 
relieving  the  pain.  The  patient  suffered  from  severe  and  prob- 
ably incurable  cervico-bi'achial  neuralgia;  the  poles  were 
placed,  respectively,  on  the  nape  of  the  neck  and  in  the  hand 
of  the  affected  limb,  and  whether  the  positive  was  on  the  nape 
and  the  negative  in  the  hand,  or  vice  versa,  the  effect  was  the 
same.  Very  striking  remission  of  the  pain  was  always  pro- 
duced, and  the  immunity  from  suffering  sometimes  lasted  for  a 
considerable  time,  while  no  other  plan  of  treatment  seemed  to 
have  more  than  the  most  momentary  effect. 

My  own  experience  tells  the  same  story  very  decidedly,  for 
I  have  on  very  many  occasions  obtained  great  benefit,  both  by 
the  direct  and  by  the  inverse  currents,  in  the  same  patient.  I 
shall  here  relate  a  few  instances: 

Case  I. — A  married  woman,  aged  forty-eight,  whose  men- 
strual periods  had  ceased  quietly  some  six  years  previously. 
She  was,  on  the  whole,  a  healthy  person,  but  had  suffered  from 
migraine  in  her  yout'h,  and  came  of  a  neurotic  faniily.  She 
was  attacked  with  severe  cervico-brachial  neuralgia,  which 
resisted  all  treatment  for  nearly  three  months,  and,  on  her 
then  trying  a  month's  change  of  air  and  absence  from  medica- 
tion, became  worse  than  ever.  The  constant  curx'ent  was 
applied,  from  ten  (and  afterwards  fifteen)  cells  of  Weiss's  bat- 
tery, daily  for  twenty-four  days .  the  pain  vanished  finally  at 
the  end  of  thirteen  days,  and  the  accompanying  anassthesia 
and  partial  parab^sis  disappeared  before  the  treatment  was  con- 
cluded. In  this  case  the  negative  pole  was  applied  by  the  side 
of  the  three   lower  cervical  vertebrae,  and  the  positive  was 


TREATMENT  OP  NEURALGIA.  175 

applied,  successively,  to  three  or  four  different  parts  of  the 
most  intense  peripheral  pain. 

Case  II. — A  j^oung  lady,  aged  twenty-four,  suffered  from 
neuralgia  in  the  leg.  Galvanization  (twenty  cells  Daniell). 
from  the  anterior  tibial  region  to  the  spine  was  found  invaria- 
bly to  cut  short  the  pain.  I  now  reversed  the  current ;  the 
eft'ect  was  the  same.  After  ten  sittings  I  suspended  the  treat- 
ment, as  there  had  been  no  attack  for  three  days;  but  a  week 
later  the  neuralgia  returned  in  full  fury.  I  resumed  galvani- 
zation from  periphery  to  spine;  after  twelve  more  sittings  the 
attacks  had  become  rare  and  slight.  I  continued  treatment 
for  eight  days  longer,  during  the  whole  of  which  time  there 
was  no  pain.  It  had  not  recurred  when  I  saw  her  fifteen 
months  afterward. 

Case  III. — H.  G.,  a  footman,  aged  twenty-three,  applied  to 
me  at  Westminster  Hospital,  with  neuralgia  of  the  first  and 
second  divisions  of  the  right  trigeminus,  of  six  weeks'  stand- 
ing. The  right  eye  was  bloodshot  and  streaming  with  tears, 
the  skin  of  the  right  side  of  the  nose  and  right  cheek  was  anae- 
sthetic, the  right  levator  palpebrae  was  partially  paralyzed. 
Hypodermic  injections  of  morphia  proved  only  very  tempo- 
rarily beneficial.  After  a  fortnight's  treatment  with  this  and 
with  flying  blisters  to  the  nape  of  the  neck  and  the  mastoid 
process,  I  commenced  the  use  of  the  constant  current  daily 
(ten  cells,  Weiss).  The  first  application  (positive  on  nape,  neg- 
ative on  infra-orbital  foramen)  stopped  the  pain,  and  procured 
fourteen  hours'  immunity.  On  the  next  day  I  reversed  tlie 
current;  the  pain  stopped  after  three  rhinutes'  galvanization; 
it  did  not  recur  for  four  days,  during  which  time,  however,  I 
continued  the  daily  use  of  the  direct  current.  On  the  sixth 
day  of  treatment  the  patient  came  to  me  with  a  somewhat 
severe  paroxysm,  almost  limited  to  the  ophthalmic  division;  it 
was  accompanied  by  spasmodic  twitchings  of  the  eyelid,  and 
copious  eft'usion  of  altered  Meibomian  secretion,  looking  like 
pus.  Galvanization  from  supi*a-orbital  foramen  to  nape 
stopped  the  pain  in  five  minutes.  The  next  day  the  patient 
presented  himself,  quite  free  from  pain,  which  had  not 
returned;  the  conjunctiva  was  clear,  and  there  was  no  visible 
Meibomian  secretion.  Inverse  galvanization  was  continued  for 
ten  days ;  but  no  recurrence  of  the  pain  took  place.  The  cure 
was  permanent  three  months  later. 

On  the  contrary,  we  sometimes  see  complete  failui'e  of  the 
current  to  affect  any  good  whatever;  and  in  these  cases  the 
reversalsof  the  current  has  not,  so  far,  appeared  to  me  to  make 
any  particular  change  in  the  result.  Such  was  the  case  with  a 
patient  whose  history  I  detailed  (along  with  that  of  Case  I.)  to 
the  Clinical  Society.  She  was  an  ill-fed  and  over-worked 
unmarried  needle  woman,  aged  thirty ;  the  neuralgia  was  a 
most  violent  double  occipital  pain,   with  foci,  on  each  side, 


176  TREATMENT   OP  NEURALGIA, 

■where  the  great  occipital  nerves  become  superficial.  The  cur- 
rent was  passed  daily,  for  some  days,  from  one  focus  to  anotlier 
(necessarily  passing-  through  the  nerve-roots  and  the  spinal 
cord),  and  tlie  positions  of  the  conductors  were  occasionally 
reversed ;  this  not  succeeding,  the  current  was  applied  alto- 
gether to  the  spine,  the  negative  pole  being  placed  on  the 
highest  cervical  vertebras,  but  no  good  effect  was  produced 
after  a  treatment,  altogether,  of  sixteen  days. 

Notwithstanding  these,  and  a  good  many  similar  facts  that 
could  be  adduced,  I  should  hesitate  to  go  so  far  as  to  say  that 
there  is  never  any  importance  in  the  du'ection  of  the  current. 
In  old-standing  cases,  where  there  are  well-mai'ked  points 
douloureux  that  are  exceedingly  sensitive,  I  have  found  that 
the  api^lication  of  the  positive  pole,  successively,  on  the  most 
tender  points,  the  negative  being  placed  on  the  spine  opposite 
the  point  of  orgin  of  the  nerve,  has  had  a  more  beneficial 
effect  than  any  other  mode  of  application. 

There  are  very  considerable  differences,  both  as  to  the  best 
manner  of  galvanization,  and  also  as  to  the  chances  of 
doing  good  with  it,  in  the  case  of  neuralgias  of  different 
nerves;  and,  on  the  whole,  I  find  Eulenburg's  conclu- 
sions on  this  matter  very  just.  He  indicates  sciatica  as  tho 
affection  which  is  b}^  far  the  most  curable  by  the  constant  cur- 
rent; he  says  that  many  cases  are  cured  in  from  three  to  five 
sittings,  while  others  requu'e  as  many  weel?:s,  or  even  months 
of  treatment ;  and  that  a  total  absence  of  benefit  is  only  seen 
in  rai^  cases  dependent  on  central  causes,  or  on  diseases  which 
are  irremovable  (like  malignant  pelvic  tumors).  On  the  other 
hand,  he  re]3orts  that  intercostal  neuralgia  has  never  been 
materially  benefited  by  galvanization  in  his  hands.  With 
regard  to  ordmary  trigeminal  neuralgias,  he  speaks  strongly 
of  the  current  as  a  palliative,  but  very  doubtfully  of  its  power 
to  cure,  in  genuine  and  severe  cases.  In  cervico-brachial 
neuralgia  he  speaks  of  it  as  dividing  with  hypodermic  morphia 
the  whole  field  of  useful  treatment,  in  the  majority  of  cases. 
In  cervico-occipital  neuralgia  he  says  it  rarely  does  much 
good.  I  shall  return  to  Eulenburg's  estimate  of  its  utihty  in 
migraine,  presently.  Let  me  here  say  that  I  am  inclined  to 
indorse  everything  in  the  above-detailed  statements,  excepting 
that  I  should  place  a  considerably  higher  esthnate  on  the  cura- 
tive powers  of  the  current  in  ordinary  trigeminal  neuralgias. 
The  remedy,  lil?:e  every  other,  will  doubtless  fail  in  a  consider- 
able number  of  those  very  bad  cases  which  occur  ui  the  degen- 
erative period  of  life :  but  if  anyone  desires  to  see  the  proof  of 
the  power  it  sometimes  exerts,  even  in  extreme  cases,  he  should 
study  the  two  most  remarkable  cases  treated  by  Prof.  Niemeyer, 
of  Tubingen,   and  reported  by  Dr.  Wiesner.*     The  patients 

"  Op.  cit. 


TREATMENT  OF  NEURALGIA.  s  177 

•were  respectively  aged  sixty-four  and  seventy-four,  and  the 
duration  of  the  neuralgia  had  been  I'espectively  five  and 
twenty-nine  years;  in  both  the  pain  was  of  the  severest  type, 
and  in  both  the  success  was  most  striking.  In  one  of  them 
every  possible  variety  of  medication,  and  several  distinct 
surgical  operations  for  excision  of  portions  of  the  affected 
nerve,  had  been  quite  vainly  tried.  The  cases  are  altogether 
among  the  most  mteresting  facts  in  therapeutics  that  havo 
ever  been  recorded.  Dr.  Russell  Reynolds  has  also  told  me  of 
a  case  mider  his  own  care,  in  which  a  lady,  who  had  been  the 
victim,  for  twenty  years,  of  an  extremely  severe  neuralgia  of 
the  ophthalmic  division  of  the  fifth,  which  attacked  her  daily, 
and  had  caused  great  injiiry  to  her  general  health  and  nutri- 
tion, was  not  merely  benehted,  but  the  affection  absolutely 
removed,  at  any  rate  for  a  long  period,  by  a  single  application 
of  the  current.  1  have  personally  seen,  no  such  remarkable 
cases  as  these-  but  I  have  had  some  exti'emely  severe  cases 
under  my  care  in  which  the  effect  of  the  current  was  to  arrest 
the  pain  in  a  few  applications,  and  procure  a  remission  for 
several  days,  or  even  Aveeks.  And  I  have  had  several  slighter 
cases  which  were  as  mucli  cured,  to  all  appearance,  as  any  dis- 
ease can  be,  by  any  remedy. 

As  a  general  rule,  neuralgia  of  the  limbs  requires  to  be 
treated  with  a  more  powei^ful  current  than  neuralgia  of  the 
face  (twenty  cells  instead  of  ten).  In  the  latter  case,  indeed,  it 
is  necessary  to  be  exceedingly  cautious  (commencing  with  five 
cells),  since  a  current  of  high  power  has  been  known  to  pro- 
duce most  serious  effects  upon  the  deeper-seated  organs;  the 
retina  has  been  permanently  paralyzed,  by  too  strong  a  current 
applied  on  the  face,  and  still  graver  dangers  attend  the  incau- 
tious use  of  galvanization  of  the  brain  or  of  the  sympathetic, 
of  which  we  have  now  to  speak. 

Galvanization  of  the  brain  is  a  remedy  chiefly  employed  in 
true  migraine,  and  is  certainly  very  effective  in  that  disease. 
I  have  not  found  it  useful  to  apply  the  current  in  the  long 
axis  of  the  cranium,  but  transmitted  from  one  mastoid  process 
to  the  other  it  has  proved  most  useful ;  and  I  am  glad  to  find 
that  my  experience  on  this  point  coincides  with  that  of  Eulen- 
burg.  But  the  use  of  this  remedy  is  highly  perilous  in  care- 
less hands.  In  working  with  either  Daniell's  or  Weiss's  bat- 
tery, it  is  necessary  to  use  at  first  only  three  or  four  cells,  and 
to  inci'ease  the  number  only  with  the  greatest  caution.  The 
sittings  should  never  last  more  than  half  a  minute ;  but  the 
slightest  giddiness  should  make  us  stop  even  sooner.  On  the 
other  hand,  the  applications  ought  to  be  made  daily,  and 
usually  twice  a  day.  Ten  cells  (Daniell  or  Weiss)  is  the  utmost 
that  will  ever  be  required,  few  patients  will  bear  so  much; 
and,  apart  from  the  possibility  of  more  serious  mischief,  there 
is  nothing  which  annoys  and  frightens  patients  more  seriously 


178  TREATMENT  OP  NEURALGIA. 

than  the  sudden  and  intense  vertigo  which  over-galvanization 
of  tlie  brain  may  induce. 

Even  more  ticklish  tlian  the  galvanization  of  tlie  cerebral 
mass  is  galvanization  of  the  sympathetic.  I  am  not  going  to 
raise  here  the  vexed  question  in  physiological  electricity  as  to 
the  possibility  of  a  galvanization  the  effects  of  which  shall  be 
accurately  limited  to  the  sympathetic.  The  fact  is  unquestion- 
able, that  very  powerful  and  peculiar  effects,  utterly  unpro- 
curable in  any  other  way,  can  be  x>roduced  by  placnig  one 
pole  on  the  superior  cervical  ganglion  (just  behind  and  below 
the  angle  of  the  jaw)  and  the  other  on  the  manubrium  stei^ni. 
This  is  a  mode  of  galvanizatisn  which  has  been  highly  praised, 
more  especially  by  Remak,  and  after  him  by  Benedikt,  but  it 
has  yielded  rather  disappointing  results  in  neuralgia  in  my 
hands.  Either  I  have  not  observed  any  distinct  effect  at  all, 
or,  if  a  current  even  a  very  little  too  strong  were  applied,  I 
have  repeatedly  seen  most  uncomfortable,  and  sometimes  very 
alarming,  symptoms.  I  shall  not  easily  forget  a  patient  who 
applied  at  the  Westminster  Hospital,  suffering  from  a  severe 
form  of  facial  neuralgia,  and  who  was  persuaded  to  come  to 
my  house  and  have  his  sympathetic  galvanized.  I  used  only 
twenty  cells  of  Daniell,  but  the  current  had  not  been  applied 
more  than  a  few  seconds  when  the  patient  fell  on  the  floor, 
and  remained  in  a  state  of  half  swoon  for  a  considerable  time. 
I  allude  to  this  and  other  less  dangerous  accidents  that  I  have 
seen  follow  galvanization  of  the  sympathetic,  not  with  the 
view  to  prove  that  the  metliod.is  useless  in  trigeminal  neural- 
gia— I  should  certainly  hesitate  to  say  that,  considering  the 
large  amount  of  resp  ctable  evidence  in  its  favor — but  I  think 
that  it  is  a  procedure  requiring  the  utmost  caution,  and  mean- 
time I  have  not  personally  found  it  nearly  so  useful  as  the 
methods  already  described. 

There  are  sundry  special  applications  of  galvanism  to  par- 
ticular forms  of  neuralgia  which  require  a  few  words  of  notice. 
Of  electrical  treatment  in  regular  angina  pectoris  I  have  had 
no  experience ;  and  in  the  one  case  of  intercostal  neuralgia, 
complicated  with  quasi-anginal  attacks,  in  which  I  applied  the 
constant  current  to  the  spine  and  the  cardiac  region,  in  tlie 
direction  of  the  affected  intercostal  nerve,  no  effect  was  pro- 
duced. I  shall,  however,  mention  the  experience  of  Eulen- 
burg,  as  he  is  a  sober  and  dispassionate  writer  on  the  effects  of 
electric  treatment  in  general.  He  says  he  believes  that  in  the 
proper  use  of  the  constant  current  we  shall  discover  the  chief, 
possibly  the  only  direct,  remedy  for  angina ;  and  he  describes 
the  apparently  favorable  results  he  has  already  obtained  in 
three  or  four  cases.  The  current  was  from  thirty  cells;  the 
positive  pole  was  placed  on  the  sternum  (broad  electrode),  the 
negative  on  the  lower  cervical  vertebrae.  The  alternative 
method  which  Eulenburg  suggests,  but  has  not,  so  far,  put  in 


TREATMENT   OF  NEURALGIA,  lid 

practice,  is  direct  galvanization  of  the  sympathetic  and  vagus 
m  the  neck. 

The  apphcation  of  the  constant  current  in  neuralgic  affec- 
tions of  the  larynx  and  pharynx  is  of  most  indisputable  ser- 
vice ;  tlie  experience  of  Tobold*  upon  this  point  is  fully  borne 
out  by  my  own,  as  far  as  it  goes.  In  many  cases  it  will  be 
sufficient  to  place  the  positive  pole  (from  fifteen  cells  Weiss) 
on  the  pomum  Adami,  and  the  negative  on  the  nape  of  the 
neck,  and  to  keep  up  a  continuous  current  for  five  or  ten  min-* 
utes  daily ;  but  in  some  cases  the  direct  application  of  the  cur- 
rent to  the  pharynx  or  larynx  may  be  required ;  in  such,  a 
modification  of  Dr.  Morell  Kackenzie's  laryngeal  conductor 
will  be  found  useful.  [I  shall  have  occasion,  in  Part  II.,  to 
notice  the  superior  action  of  Faradization  in  mere  hysteric 
throat-pain,  as  distinguislied  from  true  neuralgia.] 

Neuralgia  of  the  testicle  can  be  best  treated,  if  galvanism  be 
thought  necessary,  by  immersing  the  whole  scrotum  in  a  basin 
of  salt  and  water,  in  which  the  positive  pole  is  placed:  the 
negative  pole  is  to  be  placed  on  the  upper  lumbar  vertebrae ;  the 
current  should  be  from  fifteen  cells  Weiss,  and  the  application 
should  last  continuously  for  ten  minutes.  In  neuralgia  of  the 
urethra,  I  should  be  inclined  to  adopt  a  plan,  mentioned  to  me 
by  Dr.  Buzzard,  of  attaching  one  conductor  to  an  ordinary 
silver  catheter  introduced  into  the  urethra,  and  placing  the 
other  pole  upon  the  perinaaum. 

Neuralgia  of  the  neck  of  the  bladder  I  have  found  to  be 
materially  relieved  by  the  constant  current  from  twenty  cells 
passed  through  from  pubis  to  perinaeum;  the  sittings  being 
rather  long.  I  have  also,  on  one  occasion,  tried  the  introduc- 
tion of  a  proper  porte-electricite,  insulated,  except  at  the  tip; 
but  the  result  was  not  superior  to  that  obtained  in  the  other 
way. 

As  a  general  rule,  it  may  be  said  that  electricity,  like  other 
local  measures  which  tend  to  concentrate  the  patient's  atten- 
tion on  the  parts,  is  only  to  be  applied  to  the  genital  organs  as 
a  last  resort.  This  is,  of  course,  especially  true  in  the  neural- 
gias of  these  organs  in  women. 

In  concluding  what  will  doubtless  seem  to  some  English 
readers  an  over-long  and  over-favorable  estimate  of  the 
Bmployment  of  galvanism  in  neuralgias,  I  must  carefully  guard 
myself  against  the  supposition  that  I  consider  it  a  remedy  to  be 
applied  in  all  cases,  or  likely  to  meet  with  uniform  success, 
even  in  the  forms  of  the  disease  to  which  it  is  most  appropriate. 
It  is  a  weapon  which  I  seldom  employ  in  the  first  instance,  for 
many  reasons;  the  principal  of  which  is  the  costliness  of  the 
proceeding  to  the  patient.  Either  the  physician  must  person- 
ally administer    the  remedy,  daily,  often  for  a  considerable 

*  Berlin,  klin.  ■Wochenscli.,  23,  1865. 


180  TREATMENT  OF  NEURALGIA. 

period,  or  lie  must  make  the  patient  provide  himself  with  an 

expensive  battery ;  and  m  the  latter  case  there  is,  after  all,  the 
unsatisfactory  consideration  that  the  application  (even  after 
the  most  careful  directions  have  been  given)  will  perhaj)s  be 
unskilfully  and  inefficiently  made.  On  the  other  hand,  it  is 
not  desirable  to  delay  the  employment  of  galvanism  too  long, 
if  other  remedies  have  been  fairly  tried ;  and  the  practitioner 
will  do  well  to  remember  the  distinctions  above  laid  down  as 
to  the  varieties  of  neuralgia  in  which  it  is  specially  likely  to 
prove  decidedly  and  quickly  beneficial.  More  especially  in 
sciatica  it  would  really,  with  our  present  knowledge,  be  a 
decided  neglect  of  duty  were  we  to  allow  the  disease  to  run  any 
considerable  length  without  giving  the  constant  current  a 
thorough  trial.  [I  can  only  briefly  refer,  here,  to  the  novel 
mode  of  galvanization  introduced  by  Dr.  RadclifFe,  and  based 
upon  his  ingenious  theory,  according  to  which  the  true  effects 
of  the  voltaic  current  upon  nerve  are  the  result  of  the  charge 
of  free  electricity  which  it  sets  up,  and  not  of  the  current 
directly.  The  reader  will  find  the  whole  argument  elaborately 
worked  out  in  Dr.  RadclifPe's  recent  woi'k  on  "  The  Dynamics 
of  Nerve  and  Muscle,"  Macmillan  &  Co.,  1871.  It  will  be 
enough  to  say,  here,  that  the  object  to  be  attai;ied,  according 
to  this  view,  is  to  replace  the  neuralgic  nerve  in  its  healthy- 
physiological  state,  by  chai'ging  it  with  free  positive  electri- 
city. The  manner  in  which  this  is  done  is  as  follows :  In  a 
case,  e.  g  ,  oi  cervico-brachial  neuralgia,  we  ijlace  the  positive 
pole  as  near  as  may  be  to  the  centi'al  origin  of  the  affected 
nerve ;  the  negative  pole  is  held  in  the  hand  of  the  same  side, 
which  is  immersed  in  a  basin  of  warm  salt  and  water.  In  this 
same  basin  is  another  electrode,  the  wire  from  which  is  put  in 
communication  with  the  earth — most  conveniently  by  5)utting 
it  in  contact  with  a  gas-pipe.  The  patient,  and  the  battery, 
ought  properly  to  be  insulated.  The  result  of  this  arrange- 
ment is,  that  the  free  negative  electricity  is  carried  off  by  the 
earth-wire,  and  the  limb  remains  charged  with  free  positive 
electricity.  I  have  had  no  sufficient  experience  of  this  method 
to  give  any  opinion  of  its  merits,  but  the  inventor  thinks  it 
decidedly  superior  to  the  ordinary  modes  of  applying  the  con- 
stant current.] 

(/)  The  last  kind  of  local  remedies  for  neuralgia  of  which 
we  have  to  speak  are  those  by  which  we  seek  to  mitigate  the 
paroxysm  by  thoroughly  excluding  the  air  from  the  site  of 
apparent  pain.  These  are  chiefly  of  value  in  those  cases  where 
a  distinct  inflammation  (herpetic  or  erysipelatoidj,  or  an 
unusual  degree  of  sensitiveness  on  pressure,  etc.,  has  become 
developed  around  the  superficial  branches  of  the  neuralgic  nerve. 
Very  much  the  best  agent  of  this  kind  with  which  I  am 
acquainted  is  the  flexible  collodion ;  in  neuralgic  herpes  and 
erysipelas  the  effect  of  this  application,  conjoined  with  the 


TREATMENT  OP  NEURALGIA.  181 

1i5T)oderinic  injection  of  morphia  (preferably  in  the  immediate 
neighborhood),  is  of  the  greatest  possible  service  in  mitigating 
the  pain.  In  herpes  it  has  this  further  special  advantage,  that 
it  prevents  the  occurrence  of  sores  after  the  vesicles  fall,  an 
accident  vv^hich  otherwise  v/ill  sometimes  happen,  and  which 
very  much  increases  the  severity  and  intractability  of  the  con- 
secutive neuralgic  pain. 

4.  Lastly,  we'have  to  speak  of  prophylactic  measures,  which 
really  ought  never  to  be  thought  of  as  a  separate  matter,  but 
always  as  an  essential  and  m.ost  important  part  of  the  treat- 
ment of  neuralgia.  The  prophylaxis  of  neuralgia  is  divisible 
into  (a)  measures  for  preventing  the  development  of  the 
neuralgic  habit  in  those  who  may  be  supposed  to  have  a  pre- 
disposition to  it ;  (6)  measures  between  the  paroxysms ;  (c)  mea- 
sures to  be  adopted  after  the  attacks  have  ceased. 

(a)  The  measures  that  should  be  taken  to  avert  neuralgia,  in 
those  who  may  be  reasonably  assumed  to  be  predisposed  to  it, 
have  scarcely  received  any  consideration  at  the  hands  of  sys- 
tematic winters ;  yet  this  is  a  most  important  subject.  The 
persons  in  question  are  children  who  belong  to  families  known 
to  be  infected  with  tendencies  to  neurotic  diseases,  or  persons 
whose  daily  occupations  submit  them  to  peculiarly  strong  pre- 
disposing iniluences  of  an  external  kind.  The  hostile  influ- 
ences that  should  be  avoided,  or  at  any  rate  compensated,  are 
of  several  kinds :  (1)  Psychical ;  (2)  defects  of  nutrition ;  (3)  mis- 
management of  the  muscular  system ;  (4)  sexual  irregularities ; 
(5)  over-fatigue  of  the  special  senses,  and  insufficiency  of  sleep, 
especially  the  latter ;  (6)  unhealthy  atmosphere  and  climate. 

(1)  The  psychical  nifluences  which  must  be  especially  avoided, 
if  we  would  avert  the  formation  of  the  neuralgic  habit,  form 
a  large  and  somewhat  indefinite  group,  which  it  is  doubtless 
difficult  to  deal  with  satisfactorily.  The  matter  is,  however, 
highly  important,  and  the  attempt  must  be  made.  And  there 
are,  at  any  rate,  some  leading  principles  that  I  feel  justified  in 
laying  down  with  confidence. 

We  shall  best  commence  the  inquiry  by  directing  our  atten- 
tion once  more  to  the  fact,  so  often  insisted  upon  in  this  v/ork, 
that  the  large  majority  of  neuralgic  patients  carry  in  them  the 
seeds  of  their  malady  from  their  birth.  It  has  been  amply 
proved  that  every  child  born  of  a  family  that  has  shown  strong 
tendencies  to  insanity,  epilepsy,  paralysis,  etc.,  etc.,  ought  to 
be  looked  on  as  a  neurotic  subject,  and  as  a  potential  sufferer 
from  neuralgia.  It  has  been  shown  that  sucla  childi-en  will  be 
exposed,  even  under  favoring  external  circumstances,  to  the 
danger  of  neuralgia  at  certain  important  stages  of  their  physio- 
logical history.  The  earliest  of  these  critical  periods  is  marked 
by  the  occurrence  of  puberty;  and  it  is  not  till  this  time  that 
psychical  influences,  as  such,  come  to  have  any  serious  bear- 
ing on  the  formation  of  the  neuralgic  habit.     Mischief  may, 


183  TREATMENT  OF  NEURALGIA. 

indeed,  be  done  to  the  brain  and  the  general  nervous  system, 
by  m judicious  mental  training,  at  a  far  earlier  period,  but 
this  mischief,  serious  or  even  fatal  as  it  may  be,  usually  takes 
some  other  form  than  that  of  neuralgia.  It  will  be  necessary, 
here,  to  reflect  a  little  upon  certain  features  of  the  childish 
mind_^  in  order  that  we  may  rightly  estimate  the  kind  of  influ- 
ence which  puberty  exerts  upon  it. 

A  very  young  child  is  selfish,  in  the  purely  animal  sense ;  it 
is  greedily  acquisitive,  a,nd  its  selfishness  is  unchecked  by  any 
sense  of  shame.  With  later  childhood  there  comes  a  sense  of 
right  and  wrong,  and  a  sensitiveness  to  shame,  which 
check  this  tendency ;  still  it  is  the  exception  rather  than  the 
rule  to  find  any  great  capacity  of  self-abnegation  in  young 
school-boys.  But  a  modei-ately  healthy-minded  child,  up  to 
the  age  of  puberty,  is  only  acquisitively  selfish ;  he  is  not  self- 
centered  in  the  sense  of  dwelling  upon  his  own  mental  state, 
and  reflecting  upon  the  nature  of  his  motives  and  feelings.  It 
is  with  the  age  of  puberty  that  self-conscioLisness  begins  to  be 
a  feature  in  the  mind  of  the  young,  and  its  appearance  marks 
the  entrance  of  a  dangerous  element  into  the  character.  It  is 
an  inevitable  stage  in  mental  growth,  and,  if  wisely  dealt  with, 
is  ultimately  productive,  not  of  evil,  but  of  good ;  but  it  is 
more  perilous  to  some  children  than  to  others,  and  it  is  espe- 
cially fraught  with  danger  to  those  whose  nervous  centres  are, 
by  inheritance,  weak  and  unstable  in  whole  or  in  parts.  The 
mental  antidote  to  its  possible  evil  effects  is  to  be  found  in  a 
vigorous  (but  not  excessive)  training  of  the  mind  in  studies 
which  shall  be  as  far  as  possible  external,  and  the  discourage, 
ment  of  all  tendencies  to  introspection.  I  would  venture  to 
express  the  decided  opinion  that  the  common  idea,  that  close 
study  injures  the  young,  is  only  true  in  a  modified  sense.  It 
is,  however,  unquestionably  the  fact,  that  hasty  and  imperfect 
cram-work  does  very  seriously  impair  the  stability  of  the  brain 
and  the  nervous  system  in  young  people ;  there  is  a  spurious 
exciternent  about  this  kind  of  learning  (especially  when  it  is 
mainly  competitive,  and  directed  to  the  gaining  of  prizes  and 
medals)  which  must  be  m  jurious.  But  I  think  it  is  quite 
ridiculous  to  suppose  that,  in  this  country,  the  actual  amount 
of  intellectual  labor  undergone  by  boys  and  gnls  at  school  is 
suflBcient  to  do  harm,  were  it  onlj^  regular  and  systematic,  and 
carried  out  in  a  conscientious  manner ;  on  the  contrary,  though 
I  think  that  the  total  daily  period  occupied  in  study  ought  not 
to  exceed  some  six  or  seven  hours,  I  believe  that  the  insisting 
on  strenuous  diligence  during  school  hours,  and  the  main- 
tenance of  a  high  standard  as  to  the  quality  of  the  work 
exacted,  is  all  on  the  side  of  nervous  health.  But,  an 
even  more  serious  and  difficult  matter  than  the  regulation  of 
the  amount  of  intellectual  work  to  be  done  is,  the  question 
how  we  are  to  deal  with  the  unfolding  emotional  instincts  of 


TREATMENT  OP  NEURALGIA.  183 

the  boy  or  girl  who  has  reached  the  age  of  puberty.  It  is  use- 
less to  ignore  this  side  of  the  mental  life ;  it  will  assert  itself 
either  for  good  or  for  evil.  At  tlie  risk  of  seeming  to  meddle 
with  matters  that  belong  to  the  school-master  rather  than,  to 
the  physician,  I  would  urge  very  strongly  that  a  portion  of  the 
training  be  deliberately  directed  to  a  serious  study  of  one  or 
other  of  the  fine  arts — to  that  one,  whether  poetry,  painting, 
sculpture,  or  music,  to  which  the  boy  or  the  girl  instinctively 
leans.  I  am  aware  that  there  is  a  prejudice  among  parents 
that  the  study  of  the  fire  arts  renders  young  people  idle  and 
mdiff  erent  to  other  branches  of  education  and  other  duties  of 
life.  I  believe  that  this  only  applies  to  the  miserably  ineffi- 
cient way  of  teaching  these  subjects  which  prevails  at  present 
in  all  but  a  few  English  schools;  and  that,  in  truth,  a  thorough 
knowledge  of  the  principles  of  either  music  or  painting,  and  a 
real  study  of  the  best  masters,  would  be  sure  to  prevent  the 
development  of  that  lazy,  conceited  manner,  and  that  neglect 
of  other  duties,  which  no  doubt  unfavorably  distiiiguish  a  good 
many  of  the  young  ladies  and  gentlemen  who  dabble  a  little 
in  muSiC,  or  painting,  or  versification.  We  want  the  G-erman 
rather  than  the  English  type  of  training,  we  want  the  acquire- 
ment of  sound  knowledge  of  the  principles  of  music  (at  any 
rate)  to  be  made  so  common  that  the  accidental  possession  of 
two  pennywoi'th  of  superficial  accomplishment  in  that  line 
shall  not  enable  young  lad  ies  and  gentlemen  to  give  themselves 
airs  in  society.  The  truth  is,  that  the  young  people  who  make 
music  or  painting  an  excuse  for  idleness  respecting  other  mat- 
ters are  invariably  imposters.  even  in  that  which  is  their  own 
supposed  forte.  On  the  other  hand,  the  serious  study  of  art, 
a  certain  definite  portion  of  time  being  set  apart  for  it,  and 
thoroughness  being  insisted  upon,  is,  I  believe,  an  admirable 
vent  for  the  emotional  eifervescence  of  commencing  sexual 
life ;  and  I  no  less  firmly  believe  that  the  things  that  are  usu- 
ally substituted  for  it,are  intensely  pernicious.  I  have  already, 
in  the  chapter  on  Patlaology,  remarked  on  the  m^^chief  which 
is  often  done  by  the  anxiety  of  religious  parents  to  make  their 
cliiidren  (usually  somewhere  about  this  perilous  time  of 
puberty)  experience  tlie  emotional  struggle  which  is  believed 
to  end  in  a  change  of  heart  and  principles.  I  need,  therefore, 
only  now  repeat  the  expression  of  my  intense  conviction  that 
the  results  of  this  process,  as  seen  by  the  physician  to  occur 
within  that  mental  region  where  the  emotions  and  the  organic 
nervous  system  come  into  closest  relations,  are  simply  disas- 
trous. It  is  not  my  business  to  suggest  the  proper  alternative 
to  a  mode  of  spiritual  training  which  I  think  deleterious ;  lean 
only  intimate,  in  the  most  general  way,  my  belief  that  a  calm 
and  systematic  training  in  the  simplest  principles  of  duty  and 
religion  is  greatly  more  suitable  to  the  immature  mind  and 
brain  of  youth  than  any  strong  emotional  excitement  on  such 


184  TREATMENT  OF  NEURALGIA. 

topics.  But  if  ill-regulated  spiritual  emotion  of  a  religious 
kind  be  a  dangerous  thing  for  young  pei'sons  in  the  most  seri- 
oue  crisis  of  bodily  development,  far  more  decidedly  perni- 
cious is  the  spurious  excitement  of  feeling  which  is  directed  to 
lower  and  often  most  unworthy  objects .  The  increasing  pre- 
cocity of  boys  and  girls,  in  their  familiarity  with  the  most 
objectionable  aspects  of  passion  and  intrigue,  is  steadily  fed,  in 
the  present  day,  by  a  system  that  allows  them,  too  often, 
unlimited  access  to  light  literature  which  (as  is  strikingly  the 
case  with  many  novels  of  our  day)  is  at  once  devoid  of  true 
literary  and  artistic  merit,  and  at  the  same  time  replete  with 
sensational  incident  of  a  vulgarly  exciting  kind.  _  The  same 
degrading  tendency  is  very  distinctly  to  be  noted  in  the  char- 
acter of  the  dramatic  and  other  public  exhibitions  which  are 
most  popular  at  the  present  day ;  the  main  characteristics  being, 
bad  art,  and  thinly- veiled  sensuality,  all  the.  more  pernicious 
for  being  veiled  at  all.  It  would  be  a  hundred  times  better  that 
a  boy,  or  even  a  girl,  should  study  the  frank  and  outspoken 
descriptions  to  be  found  in  Shakespeare  or  Fielding,  with  all 
their  occasional  coarseness,  than  that  they  should  enervate 
their  minds  with  the  sickly  trash  that  is  most  current  and  most 
popular  at  the  present  day.  in  theatre  and  circulating  library. 
(2)  The  defects  of  nutrition  that  assist  the  development  of 
the  neuralgic  tendency  are  often  the  consequence  of  a  system 
which,  it  is  to  be  hoped,  is  to  a  large  extent  becoming  effete, 
but  ^vhich,  nevertheless,  survives  in  sufhcicient  vigor  and 
extent  to  demand  express  reprobation.  It  was  till  lately  the 
general,  and  it  is  still  a  too  common  practice,  to  keep  children 
and  young  persons  on  a  very  insufficient  allowance  of  the 
most  impoi'tant  elements  of  food;  the  state  of  things  in  this 
respect,  both  in  public  and  private  schools,  in  the  first  half  of 
the  present  century,  is  a  lasting  reproach  to  the  medical  prac- 
titioners of  those  days,  who  scarcely  lifted  a  finger  to  amend 
it,  even  when  they  did  not  expressly  approve  it,  under  the 
influence  of  absurd  theories  about  the  dangers  of  excessive 
"  grossness  of  blood."  It  is  indeed  amazing  that,  with  the  pal- 
pable fact  staring  them  in  the  face,  of  the  rapid  and  incessant 
additions  to  tissues  which-  are  being  made  by  children  and 
young  people,  medical  men  should  have  failed  to  perceive  the 
necessity  for  supplies  of  food  practically  unlimited  except  by 
the  capacity  of  digestion.  Yet  this  seems  hardly  ever  to  have 
been  thought  of,  and  tlie  unfortunate  results  seem  scarcely  to 
have  been  noticed,  except  when  they  led  to  emaciation  or 
consumptive  disease.  But  the  effects  were  perhaps  even  more 
disastrous  where,  with  a  maintenance  of  a  fair  amount  of 
muscular  nutrition,  there  was  only  a  little  dyspepsia,  and  per- 
haps some  slight  tendency  to  nervousness,  to  show  that  any- 
thing was  wrong.  The  children  who  were  born  of  strong  and 
healthy  parents,  may  have  suffered  comparatively  little  from 


TREATMENT  OF  NEURALGIA.  185 

this  regimen  as  regards  their  nervous  system,  but  those  "who 
were  born  of  neurotic  ancestors  undoubtedly  suffered  exten- 
sively. The  crisis  of  puberty  was,  in  such  ill-nourished  chil- 
di^en,  too  frequently  the  signal  for  an  explosion  of  epilepsy, 
chorea,  or  neuralgia;  and  too  often  tlie  mischief  was  yet  fur- 
ther increased  by  a  most  in  judicious  medical  treatment,  includ- 
ing a  deterioration  rather  than  an  improvement  in  the  already 
insufficient  dietai'y  system.  At  the  present  day,  however,  we 
may  fairly  hope  that  common  sense  is  prevailing,  so  as  to  put 
an  end  to  this  mischief  as  regards  the  children  of  the  upper 
and  middle  classes.  Unfortunately,  with  the  poor  a  similar 
ill-nourishment  of  the  young  is  too  often  inevitable,  and  the 
consequences  are  constantly  to  be  traced  in  enf  eeblement  of  the 
nervous  system,  of  which  neuralgia  is  a  pretty  common  result. 

It  cannot  be  two  frequently  repeated  that  for  those  children, 
more  especially  those  who  come  of  nervous  families,  any 
considerable  error  in  this  direction  has  a  fatal  tendency 
to  awaken  the  disposition  to  nervous  disease.  At 
every  step  of  the  infancy,  childhood,  and  youth  of 
such  persons,  the  most  generous  allowance  of  the  more 
nutritive  elements  of  food  is  of  the  first  importance.  At 
the  same  time  I  am  entirely  opposed  to  the  practice  of  giving 
stimulants  to  any  considerable  extent,  or  indeed  to  any  extent, 
save  in  exceptional  instances.  Good  meat,  bread,  milk,  butter, 
fruit,  and  vegetables,  are  really  the  efficacious  means  of  forti- 
fying the  nervous  system  against  the  impending  dangers. 
With  hospital  out-patients,  for  whom  we  cannot  command 
such  diet,  our  best  course,  whenever  they  show  signs  of  defi- 
cient nutrition,  will  be  the  steady  administration  of  cod-liver 
oil  for  a  long  period. 

(3)  The  true  and  proper  training  of  the  muscular  system  is 
among  the  most  important  means  of  antagonizing  the  tendency 
to  the  development  of  the  neuralgic  habit.  It  is  a  great  mis- 
take to  suppose  that  over-training  in  athletics  of  any  kind  is 
of  use;  but  the  sytematic  employment  of  means  which  tend  to 
make  the  muscular  system  hardy  and  efficient  is  of  very  great 
benefit.  The  parents  of  children  who  may  be  supposed  by 
inheritance  to  possess  a  tendency  to  neuralgia  would  do  well 
to  study  such  a  methodical  series  of  directions  as  those  which 
are  given  by  Mr.  Maclaren,  in  his  excellent  work  on  physical 
training.  I  suspect  that  the  benefit  of  judicious  gymnastics  is 
wrought  in  two  ways:  first,  by  its  improving  circulation  and 
general  nutrition,  including  the  nutrition  of  the  nervous  cen- 
tres ;  and,  secondly,  that  it  gives  the  nervous  centres  an  educa- 
tion, so  to  speak,  by  the  variety  of  difficult  co-ordinative  move- 
ments over  which  it  trains  those  centres  to  preside.  But 
unquestionably  the  matter  is  a  science,  not  a  mere  rude  art, 
and  requii^es  to  be  studied  as  such. 

(4)  Of  unspeakable  importance  to  the  object  of  averting  tM 


186  TREATMENT  OF  NEURALGIA. 

formation  of  the  neuralgic  habit  is  the  prevention  of  sexual 
irregulaiities  in  the  young.  Under  this  heading  is  included  a 
large  and  various  grouj)  of  influences ;  of  these  the  first  tliat  re- 
quires notice  is  the  prevention  of  precocious  sexual  stimulation, 
whether  by  talk  or  by  acts,  which  may  prec  ipitate  the  occurren  ce 
of  puberty  at  an  unnaturally  early  age.  I  know  very  well  how 
difficult  it  is  to  devise  any  scheme  which  really  would  effec- 
tively control  and  antagonize  the  worst  mischief  of  schools ;  but 
it  is  at  least  a  duty  to  say  here,  that  no  experienced  physician 
can  doubt  that  such  a  scheme  must  be  found,  if  we  are  ever  to 
hope  for  a  healthier  race  of  children  and  of  young  men  and 
women,  and  if  we  are  to  break  down  one  of  the  most  potent  of 
the  influences  that  go  to  the  production  and  maintenance  of 
the  neurotic  disposition.  I  Avould  be  clearly  understood  not  to 
suppose  for  a  moment,  either  that  this  sort  of  cause  is  usually 
at  work  in  the  production  of  neuralgia  in  the  young,  or  that  of 
itself  it  is  sufficient  to  produce  the  disease ;  but  I  would  say, 
for  certain,  that  on  children  of  nervous  families  such  influences 
act  with  disastrous  energy;  and,  moreover,  that  where  we  see 
signs,  in  a  neuralgic  young  person,  of  that  general  form  of 
bad  health  which  is  connected  v/ith  precocious  puberty,  we 
may  be  nearly  certain  that  such  influences  have  actually  been 
at  work.  At  all  cost,  and  by  all  conceivable  means,  all  chil- 
dren, but  most  especially  the  delicate  and  nervous  ones,  ought 
to  be  shielded  from  the  risk  of  this  occurring. 

Another  form  of  sexual  irregularity  which  can  be  counted 
as  a  contributor  to  the  formation  of  the  neuralgic  habit  is  men- 
strual irregularity,  especially  at  the  commencement  of  sexual 
life.  By  far  tne  most  mischievous  in  this  way  is  menorrhagia 
of  the  young.  I  have  seen  exceedingly  severe  and  intractable 
neuralgia  set  up  by  it .  As  regards  the  influence  of  simple 
amenorrhoea,  I  am  by  no  means  clear :  it  seems  pretty  nearly 
as  likely  that  the  deficient  excretion  (when  not  dependent  on 
mechanical  cause)  is  a  mere  sign  of  the  general  weakness 
which  also  predisposes  to  the  neuralgia,  as  that  the  neuralgia  is 
in  any  way  the  direct  consequence  of  the  amenorrhoea . 

Leucorrhcea,  especially  when  jjrofuse  and  long-continued,  is 
a  much  more  indisputable  factor  in  many  neuralgias.  It  is  a 
point  of  real  importance  to  put  an  end  promptly  to  such  a  dis- 
charge, if  it  exists,  and  the  usual  remedies — cold  bathing,  mild 
astringent  injections,  etc. — should  be  at  once  prescribed. 

Dysmenorrhoea,  a  painful  menstruation,  when  not  depen- 
dent on  a  purely  mechanical  cause,  affords  a  sti'ong  example 
of  neuralgia  connected  with  sexual  difficulty ;  but  there  is  every 
reason  to  think  that  the  neui^algia  is  the  primary  and  not  the 
secondary  affection.  Tlie  only  effective  prophylaxis,  there- 
fore, is  the  adoption  of  such  general  measures  as  will  raise  the 
whole  tone  of  nervous  health.  It  often  happens  that  marriage 
completely  cures  the  tendency  to  these  attacks. 


TREATMENT  OF  NEURALGIA.  187 

(5)  Insufficiency  and  irregularity  as  to  the  allowance  of 
sleep  ax'e  potent  influences  in  developing  neuralgia  in  those 
who  are  hereditarily  predisposed.  It  is  needless  to  say  a  single 
word  to  prove  the  imperative  need  of  the  young  for  periodical 
and  prolonged  repose  from  the  conscious  actions  of  the  nervous 
system.  Full  ten  hours  of  sleep  in  the  twenty-four,  for  boys 
and  girls  who  ai^e  at  or  near  the  j)eriod  of  puberty,  is  an  abso- 
lute necessity  if  we  would  prevent  any  existing  irritability  of 
the  nervous  system  from  developing  into  the  fully-formed  neu- 
rotic temperament.  Indeed,  I  believe  that,  for  all  young  peo- 
ple (but  especially  girls)  up  to  the  age  of  twenty-five,  this 
allowance  is  not  the  least  beyond  what  is  necessary :  only  the 
need  is  most  pressing  at,  and  just  before,  the  development  of 
the  sexual  organs.  Of  course  a  much  larger  allowance  of 
sleep  is  necessary  in  actual  infancy :  from  seven  to  twelve  we 
may  be  content  if  we  get  nine  hours  clear  sleep;  but  during 
the  two  or  three  years  preceding  puberty  we  should  insist  upon 
ten  hours,  at  any  rate  for  children  who  possess  the  nervous 
temperament. 

(6)  Impurity  of  the  atmosphere  in  which  they  habitually  or 
daily  reside  must  be  carefully  shunned  for  young  children, 
especially  for  the  nervous.  The  kind  of  dull  and  diffused 
headache  which  children  often  complain  of,  after  study  for 
some  time  in  a  close,  ill- ventilated  school-room,  is  very  likely 
(if  the  b?.d  influence  be  continued  for  a  nuraber  of  years)  to 
develop  itself,  at  puberity,  into  a  regular  migraine.  Purity  of 
air  in  the  school-room  must  therefore  be.scrupulously  provided 
for ;  and  the  same  thing  must  be  attended  to  as  regards  the 
slee]3ing  rooms. 

Of  the  climatic  influences  we  may  speak  in  a  few  words. 
Besides  the  avoidance  of  distinctly  malarial  districts,  and  also 
of  places  where,  although  there  is.no  distinct  ague,  there  is  a 
prevalence  of  neuralgic  or  even  of  so-called  "rheumatic"  com- 
plaints, it  is  necessary  very  carefully  to  shun  damp  soils,  and 
places  where  there  is  a  great  deal  of  harsh  and  cold  wind. 
Mere  lowness  of  average  temperature  is  not  in  itself  a  strong 
predisposer  to  neuralgia,  at  any  rate  if  guarded  against  by 
abundant  food  and  the  use  of  such  clothes  as  will  prevent 
children  from  ever  feeling  chilly  and  depressed.  But  damp 
and  harsh  winds  are  actively  bad ;  and  when  joined  to  habitual 
or  frequent  lowness  of  temperature,  they  constitute  very 
unfavorable  surroundings  for  the  nervous  systems  of  delicate 
children. 

(b)  We  come  now  to  the  prophylaxis  which  is  to  be  adopted 
in  the  intervals  of  the  paroxysms  when  neuralgia  has  been 
actually  set  up.  This  consists  essentially  in  three  things :  (1) 
Physiological  rest,  as  perfect  as  possible,  of  the  affected  parts ; 
(2)  protection  from  cold;  3  protection  from  sunhght;  4 
avoidance  of  injurious  mental  emotions. 


188  TREATMENT   OF  NEURALGIA. 

1.  The  maintenance  of  physiological  rest,  to  the  greatest 
extent  that  is  possible,  is  an  absolute  necessity,  if  we  would 
shield  a  nerve,  which  has  lately  been  attacked  with  neuralgia, 
from  fresh  paroxysm^s.  The  most  evident  illustrations  of  this 
fact  are  afforded  by  those  neuralgic  affections  in  which  it  is 
most  difficult  to  adopt  this  precaution.  Thus  the  greatest 
embarrassraent  from  this  cause  is  met  with  in  the  case  of 
sciatica ;  a  mild  case  is  often  converted  into  one  of  great  sever- 
ity and  intractibility  because  the  patient,  in  the  early  stages, 
either  cannot  or  will  not  maintain  the  recumbent  post-ure.  So, 
too,  though  in  less  marked  degree,  the  cure  of  cervico-brachial 
neuralgia  is  often  greatly  impeded  by  the  difficulty  of  maintain- 
ing complete  rest  of  the  limb.  Again,  in  neuralgia  affecting  the 
third  division  of  the  fifth,  the  movements  of  mastication  and 
of  speech  are  a  terrible  hinderance  to  the  progress  of  recovery ; 
and  it  often  becomes  necessary,  in  severe  cases,  to  prescribe 
absolute  silence,  and  even  to  feed  the  patient  exclusively  with 
such  liquid  or  semi-liquid  food  as  shall  require  no  efforts  of 
chewing. 

2.  Preservation  from  external  cold  is  highly  important. 
When  a  nerve  of  the  arm,  or  leg,  or  trunk,  is  affected,  warm 
flannel  under-clothing  ought  immadietely  to  be  adopted.  The 
patient  who  has  been  suffering  from  cervico-occipital  neural- 
gia should  for  some  time,  m  anything  but  quite  summer 
weather,  never  go  out  without  wearing  a  warm  comforter 
romid  the  neck.  The  sufferer  from  facial  neuralgia  should  for 
some  time  after  the  cessation  of  actual  attacks  never  face  wmd 
without  wearing  a  thick  veil. 

3.  Exposure  to  bright  light  must  be  scrupulously  avoided  by 
sufferers  from  ophthalmic  neuralgia.  The  affection  known  as 
"snow-blindness"  is  really  a  neuralgia,  with  vaso-motor  compli- 
cations, produced  by  the  glai;e  of  light  reflected  from  snow ;  and 
one  of  the  severest  attacks  of  neuralgia  which  I  personally 
ever  experiened  was  provoked  in  this  way.  Even  the  com- 
paratively slighter,  but  for  an  Englishman  unusual,  glare  of 
sunlight  which  one  meets  with  during  the  first  days  of  a  Con- 
tinental holiday,  in  wandering  about  towns  made  up  of  clean 
white  stone  or  whitewashed  houses,  is  enough  to  provoke  an 
attack,  unless  the  eyes  are  carefully  guarded  with  colored 
glasses. 

4.  It  is  scarcely  necessary,  after  what  has  been  already  said, 
to  insist  upon  the  absolute  necessity  of  mental  quietude,  as  far 
as  this  can  be  obtained.  This  precaution  is  more  or  less  im- 
portant in  all  neuralgic  affections;  but  in  migraine  and  in 
other  trigeminal  neuralgias  it  is  almost  of  more  consequence 
than  any  other  prophylactic  measure ;  and  in  angina  pectoris 
it  io  so  essential  that  adoption  or  neglect  of  it  may  easily  turn 
the  scale  between  life  and  death.  All  forms  of  abdominal 
visceral  neuralgia,  also,  are  greatly  affected  by  emotion,  and 


TREATMENT  OP  NEURALGIA.  189 

passion  or  strong  excitement  of  any  kind  must  be  scrupulously- 
shunned  if  the  neuralgic  liabit  is  to  be  broken  through.  Unfor- 
tunately, it  too  often  happens  that  the  mental  surroundings  of 
the  patient  cannot  be  so  changed  as  to  enable  us  to  carry  out 
this  kind  of  propiiylaxis  effectually;  and  neuralgic  cases  of 
this  class  are  among  the  severest  trials  of  the  physician's  tact 
and  skill,  and  too  frequently  defy  his  efforts. 

(c)  The  precautionary  measures  which  are  to  be  adopted, 
after  the  neuralgic  habit  has  apparently  been  fairly  broken 
through,  in  order  to  prevent  the  patient  from  sliding  again 
into  the  old  vicious  groove,  can  hardly  be  defined  with  exactness 
thougli  their  general  character  will  be  readily  gathered  from 
the  picture  of  the  clinical  history  and  pathology  of  the  disease 
which  has  been  exhibited  at  large  in  this  work.  They  mainly 
consist  in  the  avoidance  of  severe,  and  especially  of  unequal, 
strains  upon  bodily  or  mental  powers ;  and  in  redoubled  care- 
fulness in  these  respects  at  those  natural  crises  in  the  life  of 
the  organism  which  have  been  shown  to  exercise  so  important 
an  influence  upon  the  neuralgic  tendency.  To  a  certain 
extent,  also,  but  with  much  precaution,  we  may  attempt  to 
modify  the  pheripheral  sensibility  by  what  is  commonly 
called  a  hardening  regimen.  Thus,  with  great  care,  and  pro- 
ceeding in  a  very  gradual  manner,  we  may  by  degrees  accus- 
tom the  patient  to  a  larger  amount  of  exposure  to  free  air,  and 
even  at  last  to  rough  weather,  so  that  in  the  end  he  may 
become  less  sensitive  to  some  of  the  commonest  immediately 
exciting  causes  of  neuralgia.  If  one  were  to  construct  an 
advancing  scale  of  such  measures,  one  might  arrange  them 
something  like  this:  First,  in-door  gymnastics,  and  gentle 
horse-exercise  for  out-door  work,  in  fine  weather  onlj^ ;  then 
horse-exercise  alternated  with  pedestrianism,  sea-bathing  in 
warm  weather ;  and,  finally,  we  should  try  to  reach  a  stage  at 
which  the  patient  can  well  endure  a  ten  or  fifteen  miles'  walk 
or  ride  every  day,  and  be  comparatively  careless  about  the 
weather.  In  reaching  this  latter  stage  I  have  seen  some 
patients  helped,  in  ar  extraordinary  degree,  by  the  frequent 
use  of  the  Turkish  bath,  followed  by  douche.  Upon  this  latter 
subject  I  beg  to  offer  some  remarks,  which  are  the  result  of 
pretty  careful  and  extensive  study  of  the  effects  of  the  Turkish 
bath  in  a  variety  of  chronic  nervous  diseases.  I  believe  it  to 
be  a  very  great  mistake  to  suppose  that,  either  in  rheumatism 
or  in  true  neuralgia,  the  process  of  the  bath  should  be  pro- 
longed to  such  an  extent  as  is  commonly  done.  Instead  of  the 
usual'  slow  heating  process,  gradually  carried  to  a  point  at 
which  excessive  sweating  occurs,  I  believe  that  the  really 
scientific  is  the  following:  The  patient  should  as  quickly  as 
possible  get  into  the  hottest  atmosphere  he  intends  to  expose 
himself  .to,  which  should  never  be  more  than  about  170°  Fahr. 
He  should  stay  in  this  place  just  long  enough  to  get  thoroughly 


190  TREATMENT   OP  NEURALGIA. 

hot,  and,  with,  the  assistance  of  a  glass  or  so  of  water  drunk, 
throw  himself  into  a  free  but  gentle  perspiration.  He  should 
then  be  rapidly  shampooed,  exposed  lo  tlie  spinal  douche  for 
two  or  thi'ee  ramutes,  and  then  pass  to  the  cooling'-room.  Let 
him  beware  of  too  long  dawdhng  in  the  latter  place,  and  let 
him  avoid  smoking  there.  It  is  a  positively  dangerous  thing 
to  cool  one's  self  quite  down  to  the  normal  heat,  still  mere  so 
to  induce  the  slightest  chilliness;  the  body  should  be  still  in  a 
universal  glow  when  one  issues  into  the  street.  Over  and  over 
again  I  have  proved  iipon  myself  that  it  is  the  beneficial 
method,  whereas  the  j)rolonged  use  of  the  bath,  the  xiroduclion 
of  very  copious  sweatmg,  and  above  all  a  lengthened  coolmg 
process,  most  seriously  exhaust  the  nervous  energy. 

There  are  certain  special  considerations  as  to  the  habits  of 
life  that  require  a  word  or  two.  I  need  say  nothing  more  to 
enforce  the  views  already  put  forward  as  to  the  necessity  of 
copious  supplies  of  food.  I  need  only  refer  to  what  I  have 
already  said  about  the  decidedly  mischievous  tendency  of  any- 
thing like  habitual  excess  in  the  use  of  alcohol,  merely  adding 
a  special  caution  against  such  indulgenee  during,  and  particu- 
larly towai'd,  the  end  of  the  period  of  sexual  activity.  There 
is  one  more  topic  upon  which  something  must  be  said,  namely, 
the  extent  to  which  sexual  intercourse  should  be  allowed. 
Speaking  of  neuralgia  generally  (excluding  neuralgic  affec- 
tions of  the  sexual  organs  themselves),  it  may  decidedly  be 
said  that  the  regular  and  moderate  exercise  of  the  function, 
during  the  natural  period  of  sexual  life,  is  beneficial ;  but  that 
excess  is  always  dangerous,  and  that  the  continuance  of  sexual 
mtercourse,  after  the  powers  naturally  begin  to  wane,  is 
extremely  pernicious  in  its  tendency  to  revive  latent  tenden- 
cies to  neuralgia.  As  regards  neuralgias  of  the  sexual  organs, 
it  is  very  difficult  to  speak  positively ;  and  yet  I  believe  that 
(once  the  neuralgic  habit  broken  through  by  other  means)  it  is 
very  desirable  that  the  patient  should  live  according  to  the 
laws  of  normal  physiological  hf e. 

NOTE  I. 

ADDITIONAL  FACTS    BEARING  ON  THE    QUESTION    OF    NEUROTIC 
INHERITANCE. 

The  following  cases  must  be  now  added  to  those  recorded  in 
my  list  of  private  patients  whose  family  histoiy  has  been  ascer- 
tained with  reliable  accuracy. 

Case  I.  is  that  of  a  gentleman,  aged  forty-seven,  the  subject 
of  lumbo-abdominal  neuralgia:  no  histoiy  of  nervous  disease 
in  the  family  ;  his  mother,  however,  was  of  a  "nervous" 
temiDerament. 

Case   II. — A  gentleman,   aged  sixty-four,   suffering  from 


TREATMENT  OF  NEURALGIA.  191 

angina.  His  family  nei-vous  history  is  fearful.  On  the  father's 
side  it  is  not  possible  to  get  a  clear  account.  But  on  the 
maternal  side  there  has  been  a  strong  tendency  to  insanity  and 
suicide ;  and  in  the  patient's  own  generation  one  brother  com- 
mitted suicide  from  insanity,  and  one  sister  is  still  alive,  insane. 
An  interesting  fact  is,  that  the  mother's  family  have  shown 
an  extraordinary  proclivity  to  erysij)elas. 

Case  III.  —  The  young  gentleman,  whose  single  hut 
extremely  severe  attack  of  angina  is  previously  described, 
comes  of  a  family  in  whom  the  tendency  to  neuralgia  is 
undoubtedly  very  strongly  inherited.  His  father  is  frequently 
and  very  severely  inigraineiix,  and  in  early  life  suffered  car- 
diac symptoms  not  unlike  his  son's.  A  brother  was  also 
liable  to  attacks  of  true  migraine  between  puberty  and  the 
age  of  twenty-one. 

Case  IV. — On  the  other  hand,  a  case  of  angina  which  I  saw 
in  the  countiy,  last  year,  occurred  in  a  gentleman,  aged  fifty, 
whose  family  presented  no  traceable  neurotic  history.  But 
the  damage  inflicted  upon  his  nervous  system  by  various 
external  influences  was  quite  extraordinary.  In  some  way  or 
other  he  got  some  attacks  of  migraine  at  the  age  of  fifteen  or 
sixteen ;  for  these  he  was  treated  with  bleeding,  and  with  a 
most  savage  antiphlogisticism  generally.  From  that  time  he 
never  got  free  of  the  neuralgic  tendency .  He  used  to  have  not 
only  facial,  but  intercostal  neuralgia;  for  this  last  he  was 
repeatedly  bled,  under  the  idea  that  it  was  pleurisy.  Added  to 
all  this  he  habitually  did  an  immense  deal  of  bi^ain-work  in  his 
study,  and  for  years  had  performed  clerical  duties  of  the  most 
exacting  and  exhausting  character.  It  is  not  much  wonder 
that  these  combined  circumstances  had  sufficed  to  generate  the 
neurotic  temperament. 

NOTE  II. 

the  inhibition  theories  of  HANDFIELD  JONES  AND  JACCOUD . 

In  the  present  transitional  state  of  opinion  concerning  the 
mode  in  which  the  phenom.ena  are  produced  that  are  popularly 
known  under  the  name  of  "reflex  paralysis,"  I  cannot  pass 
without  notice  the  doctrines  of  these  two  observers.  The 
reader  will  have  perceived  that,  as  regards  the  secondary  para- 
lytic symptoms  observed  in  neuralgias,  I  explain  the  pheno- 
mena mainly  on  the  theory  of  a  process  which  is  central,  and 
not  perepheral,  in  origin.  And,  even  where,  as  in  some  few 
instances,  it  seems  possible  that  the  starting-point  was  an 
organic  affection  of  some  viscus,  we  must  always  consider  the 
possibility  that  the  link  between  this  and  the  neuralgia  and 
paralyses  was  a  neuritis  migrans  travelling  inward  to  the  sen- 
sory centre,  and  from  that  passing  over  to  motor  centres  and 


192  TREATMENT  OP  NEURALGIA. 

thus  producing  paralysis;  or  that,  without  the  mtervention  of 
any  truly  inflanimatory  process,  the  continual  impressions 
streaming  in  upon  the  cord  from  the  original  seat  of  organic 
disease  may  damage  the  nutiition  of  the  sensory  nerve-root, 
producing  a  partial  atrophy,  and  that  this  process  may  extend 
to  the  motor  root. 

It  remains,  however,  to  inquire  whether  the  influence  of 
powerful  peripheral  agencies  may  not,  in  a  purely  "func- 
tional "  manner,  disable  the  nerve-centres  for  a  time,  C8.using 
paralysis  with  or  without  neuralgia.  The  main  supporters  of 
such  a  doctrine  are  Dr.  Handflekl  Jones*  and  M.  Jaccoud.f 

Dr.  Handheld  Jones  expressly  rejects  the  theory  of  Brown- 
Sequard,  as  to  spasm  of  the  vessels  in  the  nerve-centres,  and 
we  need  not  repeat  his  arguments  on  that  head,  because  it 
seems  to  be  generally  felt  that  the  vascular  spasm  theory  will 
not  account  for  the  facts.  Jones  believes  that  the  state  i)ro- 
duced  in  the  nerve-centre  by  the  iDeripheral  influence  is  one  of 
payesis  from  shock-depression,  and  that  from  tlie  sensory  centime 
this  state  can  communicate  itself  to  motor  and  vaso-motor 
centres,  though  commissural  fibres.  He  does  not  believe  m  the 
existence  of  a  s^Decial  inhibitory  portion  of  the  nervous  system: 
he  believes  that  an  impression  may  prove  stimulating  when  it 
is  mild,  or  paralyzing  when  it  is  strong;  and  that  any  afferent 
nerve  may  convey  either  the  one  influence  or  the  other  to  the 
centres  and  thus  produce  secondary  stimulus  or  secondary 
paralyses  in  various  efferent  nerves.  Jones  has  the  distin- 
guished merit  of  being  one  of  the  first  authors  distinctly  to 
perceive  that  pain  must  rank  on  the  same  level  with  paralysis : 
hence  he  sees  nothing  unintelligible  in  the  communication  of 
paralysis  to  a  motor  centre  from  a  sensory  centre  that  was  in 
the  state  which  the  mind  interprets  as  pain . 

The  theorie  (Tepuisement  of  Jaccoud  (Erschopfungs-theoric) 
also  denies  the  possibility  of  Brown-Sequard's  idea  of  j)rolougde 
spasm  of  the  vessels  of  the  centres.  It  imagines  that  powerful 
peripheral  excitements  exhaust  the  irritalDility  of  the  nerve, 
and  tlirough  that  of  the  centres,  and  induce  a  state  of  unim- 
pressibility — analogous  to  that  which  exists  in  a  nerve  or 
nerve-centre,  which  is  included  in  the  circuit  of  a  constant  cur- 
rent. The  nervous  force  is  wasted,  and,  until  an  oi)portunity 
of  repose  is  afforded  to  the  centre,  the  faculty  of  impressibility 
cannot  again  revive. 

I  must  say  that  of  these  two  theories  I  decidedly  incline  to 
that  of  Handflekl  Jones  (though  I  imagine  that  in  reality  the 
cases  are  extremely  rare,  if  there  be  any,  in  which  the  change 
in  the  centres  is  really  only  functional  and  non -organic),     I 

*  Op.  cit. 

f  "  Les  Paraplegics  et  I'Atasie  du  Mouvement."  Par  S.  Jaccoud. 
Paris,  1864. 


TREATMENT  OF  NEURALGIA.  193 

prefer  tlie  idea  of  paralyzing  slioclc  to  that  of  exhaustion  from 
over-excitement,  from  a  consideration  of  the  nature  of  thai 
form  of  peripheral  influence  which  has  been  specially  men- 
tioned by  authors  as  competent  to  produce  this  sort  of  "reflex" 
affections,  namely,  intense  and  persistent  cold.  It  seems  to  me 
a  mere  abuse  of  words  to  speak  of  this  as  an  agent  that  could 
exhaust  the  nerve  by  over-stimulation ;  it  must  surely  exhaust 
it  in  a  much  more  direct  manner  than  this,  namely  by  the  direct 
physical  agency  of  withdrawing  heat  from  the  nerve,  and  spoil- 
ing its  phj'sical  texture,  pro  tanto .  If  such  an  effect  as  that 
which  must  thus  be  produced  on  the  nerve,  and  through  it  on 
the  centi'e,  is  to  be  looked  on  as  a  case  of  over-stimulated 
function,  then,  it  seems  to  me,  there  is  no  meaning  in  lan- 
guage, and  no  possibility  of  attaining  to  clear  ideas  on  the 
subject  of  nei'vous  influence. 

NOTE  III. 

ARSENICAL   TREATMENT  OF  VISCERALGIA. 

Since  writing  the  above  chapter  on  the  Treatment  of  Neural- 
gia, I  have  had  two  fresh  and  very  striking  examples,  in  pri- 
vate practice  of  the  power  of  arsenic  to  break  the  morbid  chain 
of  nervous  actions  in  angina  pectoris. 

The  first  example  was  that  of  a  medical  man,  aged,  seventy- 
five,  in  whom  a  neuralgia,  originally  malarial  in  origin,  and 
of  some  years'  duration,  had  fixed  itself  for  some  time  in  the 
fifth  and  sixth  left  intercostal  spaces,  and  of  late  had  become 
complicated  with  anginoid  attacks  of  an  unmistakable  charac- 
ter, though  not  of  the  highest  degree  of  severity.  The  case 
certainly  seemed  very  unpromising,  looking  at  the  patient's 
age  and  the  consequent  high  probability  that  there  was  much 
arterial  degeneration.  However,  the  use  of  Fowler's  solution 
(five  mmims  three  times  a  day)  was  commenced  and  steadily 
pushed.  The  anginoid  attacks  rapidly  diminishedin  frequency 
and  at  the  end  of  ten  days'  time  were  entirely  gone,  and  after 
one  month  of  treatment'  he  still  had  no  return  of  them, 
although  they  had  previously  been  of  daily  occurrence.  It  is 
a  curious  fact,  whether  a  mere  coincidence  or  not  I  cannot  say, 
that,  some  few  days  after  the  anginoid  attacks  ceased,  he  began 
to  experience  somewhat  severe  pains,  rheumatic  in  feeling,  but 
unattended  wdth  heat  or  swelling,  in  the  elbows,  wrists,  and 
fingers,  symmetrically.  This  has  "^aearly  disappeared,  but  he 
is  still  free  from  angina.  There  is  no  discoverable  heart-lesion 
in  this  patient. 

The  other  case  was  that  of  a  fine  old  man  of  sixty-four,  who, 
but  for  some  few  slight  attacks  of  gout,  a  few  small  calculi,  and 
a  troublesome  prostatic  affection,  had  always  enjoyed  remark- 
ably good  health,  until  about  five  months  ago,  when  he  began 


194  TREATMENT  OF  NEURALGIA, 

to  notice  tightness  across  the  chest,  etc.,  when  he  wa]li:ed  up- 
hill. About  a  fortnight  before  he  came  to  me,  he  was  seized 
with  very  violent  and  alarming  paroxysms  of  pam  across  the 
the  chest  and  running  down  both  arms,  extreme  intermittence 
of  pulse,  and  a  sense  of  impending  dissolution.  The  attack 
had  recurred  daily,  at  the  same  hour  (6  P.  M.),  ever  since; 
besides  which  there  was  an  abiding  sense  of  uneasmess  m  the 
cai'diac  region,  and  a  consciousuess  that  the  least  excitement 
or  exertion  would  bring  on  the  paroxysm.  I  put  the  patient 
on  five  minims  of  Fowler,  three  times  a  day,  with  directions  to 
take  ether  when  the  paroxysms  came.  At  the  end  of  the  first 
week  there  was  already  much  improvement,  the  pai'oxysms 
having  been  both  less  frequent  and  less  severe.  At  tiie  end  of 
a  fortnight's  treatment  he  reported  that  there  had  been  nothhig 
like  a  paroxysm  for  the  last  eight  days,  although  there  was 
still  a  good  deal  of  vmeasiness  from  time  to  time.  The  hour  at 
which  the  attack  was  expected  passed  by  absolutely  without  a 
trace  of  angina.  It  remains  to  be  seen  how  long  this  improve- 
ment will  last,  but  the  altered  state  of  things,  and  jDai'ticularly 
the  suddenness  of  the  change,  cannot  be  overlooked,  and  has 
very  much  struck  the  patient  himself.  It  is  now  six  weeks 
since  he  had  any  paroxysm; 

It  becomes  niore  and  more  apparent  that  arsenic  is  generally 
applicable  to  neuroses  of  the  vagus.  In  asthma,  I  have  long 
held  it  to  be  the  most  powerful  prophylactic  tonic  that  we  pos- 
sess. It  is  also  an  excellent  remedy  in  gastralgia ;  although  I 
have  rather  dAvelt  (in  the  text  of  this  work)  on  the  action  of 
stryclmia  in  this  disease,  I  would  not  omit  my  testimony  to 
arsenic.  Dr.  Leared  has  related  some  exceedingly  interestmg 
cases  bearmg  on  this  point.  (See  British  Medical  Journal, 
November  23  and  30,  1867.) 

NOTE  IV. 

TNPLTJENCE  OF  GALVANISM  ON  CUTANEOUS  PIGMENT. 

Dr.  Reynolds  pointed  out  to  me  the  exceechngly  ciu'ious 
fact,  which  I  have  several  times  verified,  that  the  constant 
current,  in  relievmg  facial  neuralgia,  not  unfrequently  dis- 
perses, almost  instantaneously,  the  brown  skin-pign)ent  tha^ 
has  collected  in  the  painful  region;  e.  gr.,  near  the  orbit. 

NOTE  V. 

THE  ACTUAL  CAUTERY. 

A  remedy  for  inveterate  neuralgia  which  of  late  years  I  had 
almost  discarded — the  actual  cautery — has  quite  recently 
yielded  me  very  good  iDallative  results  in  two  cases.  Its 
omission  from  the  text  of  the  chapter  on  Ti'eatment  was  an 
accident  due  to  the  effect  of  habit  in  making  one,   haK  uncon- 


TREATMENT  OF  NEURALGIA.  195 

sciously,  reckon  this  remedy  as  a  "  counter-irritant."  The 
longer  I  practise,  however,  the  more  decidedly  I  am  convinced 
that  the  actual  cautery,  if  properly  applied,  does  not  act  as  an 
irritant  at  all ;  and  this  fact  was  sufficiently  in  my  mind,  when 
writing  of  irritant  remedies,  to  made  me  omit  the  cautery  from 
that  section.  I  should  have  inserted  it  under  the  heading  of 
remedies  that  interrupt  the  conductivity  of  nerves,  and  thus 
give  the  centres  temporary  rest.  The  only  useful  way  to  apply 
it  is,  to  make  an  iron  white  hot,  and  very  lightly  brush  the 
skin  over  so  as  to  make  an  eschar  not  followed  by  suppuration. 
The  galvano-cautery  (Stohrer's  Bunsen)  is  the  best  for  the  pur= 
pose,  but  I  have  made  the  flat-iron  cautery  serve  very  well. 


PAET  II. 

DISEASES    THAT    EESEMBLE 

'N'EUEALGIA. 


CHAPTER  I. 

MYALGIA. 

Of  all  the  diseases  which  superficially  resemble  neuralgia, 
none  are  so  likely  to  be  confounded  with  it,  on  a  cursory  glance, 
as  myalgia.  More  careful  inquiry,  however,  furnishes,  in 
nearly  all  cases,  ample  means  for  distinguishing  between  the 
two  affections. 

Myalgia  is  an  exceedingly  painful  affection,  and  it  is  also 
much  more  common  than  was  formerly  supposed.  It  is  to  Dr, 
Inman  that  we  undoubtly  owe  the  demonstration  of  the  fre- 
quent occurrence  of  this  malady,  and  the  facility  with  which 
it  may  be  mistaken  for  other,  and  sometimes  much  more 
serious,  diseases,  with  very  disastrous  results.  At  the  same 
time,  I  must  express  the  opinion  that  this  ingenious  author  has 
decidedly  exaggerated  the  importance  of  this  local  disease  at 
the  expense  of  an  unjust  depreciation  of  the  frequency  and 
significance  of  other  painful  disorders  which  have  their  origin 
within  the  nervous  system. 

Myalgia  proper  includes  all  those  affections  which  are 
severally  known  as  "  muscular  rheumatism  "  (for  the  muscles 
generally),  and  "lumbago,"  "  pleurodynia,"  etc.  (according  to 
locality).  It  is  essentially  pain  produced  in  a  muscle  obliged 
to  work  when  its  struciure  is  imperfectly  nourished  or 
impaired  by  disease. 

Tlie  clinical  history  of  the  different  varieties  of  myalgia 
absolutely  requires  this  key  for  its  interpretation;  otherwise, 
the  appearance  of  the  sufferers  from  different  kinds  of  myalgia 
is  so  widely  dissimilar  that  we  should  be  exceedingly  likely  to 
miss  the  important  features  of  treatment,  which  must  be 
applied  to  them  all  in  common.  Nothing,  for  instance,  can 
be  more  strikingly  unlike  than  the  appearance  of  the  pallid, 
stunted,  under-nourishment  cobbler  who  complains  of  epigas- 
tric myalgia,  and  that  of  the  ruddy  and  muscular  navvy  who 
suffers  from  acute  lumbago,  or  the  similarly  plethoric-looldng 
country  commercial  traveller,  who  has  been  driving  in  his  gig 

196 


DISEASES  THAT  RESEMBLE  NEURALGIA.  197 

against  wind  and  rain,  and  complains  of  violent  aching  pains 
in  one  or  both  shoulders;  yet  one  and  all  of  these  individuals 
are  suffering  from  precisely  the  same  cause  of  pain,  viz.,  a 
temporarily  crippled  muscle  or  set  of  muscles  which  has  been 
compelled  to  work  against  the  grain.  Why  this  state  of  things 
should  invariably  be  interpreted  as  sensation  in  the  form  of 
acute  pain  never  absent,  but  severely  aggravated  by  every 
movement  of  the  affected  part,  is  a  matter  beyond  our  powers 
of  explanation,  we  must  accept  it  as  an  ultimate  fact  for  the 
present. 

There  is  scarcely  any  need  to  describe  the  pain  of  myalgia, 
since  almost  every  one  has  suffered  either  from  lumbago,  or  from 
a  stiff  neck  produced  by  cold.  The  pain  is  essentially  the 
same  in  all  cases ;  it  is  an  aching  actually  felt  either  in  or 
toward  the  tendinous  insertions  of  the  affected  muscles,  and 
sharply  renewed  by  every  attempted  contraction  of  those  mus- 
cles. The  variations  in  the  character  and  severity  of  the  pains 
are  really  entirely  due  to  the  greater  or  the  less  opportunity 
for  physiological  rest  which  the  muscle  can  obtain.  Thus  the 
most  obstinate  and  the  most  severe,  kind  of  myalgic  pain  is 
undoubtedly  that  of  pleurodynia — pain  in  the  intercostal  mus- 
cles and  their  fibrous  aponeuroses — a  fact  which  depends  on  the 
incessant  movements  which  these  muscles  are  compelled  to 
perform  in  the  act  of  respiration.  And  next  to  this  in  sever- 
ity and  obstinacy  are  myalgias  of  the  great  muscles  which  are 
incessantly  engaged  in  maintaining,  by  their  accurately 
opposed  contraction,  the  erect  position  of^  the  spinal  column 
and  of  the  head.  This,  rate  of  proportional  frequency  and 
severity,  however  must  betaken  as  strictly  relative;  i.  e,,  it  is 
correct  upon  the  supposition  that  the  different  sets  of  muscles 
were  equally  worked  and  that  the  state  of  nutrition  was  equal 
in  the  diffei^ent  parents.  It  is  otherwise  when  the  conditions 
are  reversed.  Thus,  the  unfortunate  cobbler  or  tailor,  who  sits 
for  long  bours  in  one  cramped  and  bent  posture,  is  continu- 
ously exerting  his  recti  abdominales  (probably  suffering  from 
an  under-nutrition  common  to  all  his  tissues)  to  a  degree  per- 
fectly abnormal,  and  out  of  all  proportion  to  the  functional 
work  he  is  getting  out  of  any  other  part  of  his  muscular  sys- 
tem. The  consequense  is,  thas  he  comes  to  us  complaining  of 
acute  epigastric,  and  sometimes  pubic,  pain,  rising  to  agony 
when  he  assumes  his  ordinary  sitting  posture,  and  only 
reduced  to  any  thing  moderate  by  the  most  complete  extension 
of  the  whole  trunk  in  the  supine  posture. 

There  is  no  need  to  dilate  at  greater  length  upon  the  varie- 
ties in  the  symptoms  of  myalgia,  according  as  it  affects  one  or 
another  part  of  the  body.  We  must  consider,  briefly  the  dif- 
ferent kinds  of  cause  that  produce  it.  The  immediate  source  of 
the  pain  being,  as  we  have  seen,  the  sense  of  embarrassment  in 
a  muscle  obliged  to  contract  when  unfit  for  the  work,  we  have 


198  DISEASES  THAT  RESEMBLE  NEURALGIA. 

to  ask  what  are  the  remoter  causes  that  can  produce  this  special 
unfitness  for  the  work  of  contraction.  They  are  three :  (a) 
Overlabor  pure  and  simple  (^.  e.,  in  proportion  to  tlie  existing 
bulk  and  quality  of  the  muscle) ;  (6)  cold,  and  especially  damp 
cold,  producing  a  semi-paralyzing  eifect  on  the  vaso-motor 
nerves,  and  causing  congestion  and  sometimes  a  little  effusion 
among  the  fibres  or  within  the  sheath  of  the  muscle ;  (c)  fatty 
degeneration  of  muscle  which  is  exposed  to  inevitable  and 
incessant  work.  Either  of  these  conditions  may  so  disable  the 
muscle  that  its  unavoidable  contractions  will  set  up  the 
myalgic  state. 

Undoubtedly  however  there_  is  something  further,  in  the 
shape  of  a  natural  predisposition  not  yet  understood,  which 
m.akes  some  patients  so  much  more  liable  to  suffer  myalgic 
pain  as  a  consequence  of  this  sort  of  influences  than  other 
persons  ai'e.  I  am  in  no  condition  to  decide  what  the  nature 
of  this  predisposition  is ;  I  feel  sure  it  is  heightened  by  an 
inherited  or  acquired  gouty  tain,  but  I  have  seen  it  in  people 
whom  there  is  no  reason  to  suspect  of  gouty  tendencies.  It 
appears  to  have  no  connection  with  true  rheumatism. 

Still  after  all  that  can  be  said,  myalgia  remains  a  disease 
chiefly  of  local  origin,  and  depending  for  nine-tenths  of  its 
causation  upon  a  derangement  between  the  balance  of  work 
and  nutrition  m  the  muscle. 

As  regards  the  diagnosis  of  myalgia  from  neuralgia,  which 
is  a  very  important  matter,  the  following  are  the  main  points 
that  we  should  recollect : 

Neuralgia.  Myalgia. 

Follows    tlie    distribution    of    a      Attacks     a    limited      patch      or 
recognizable  nerve  or  nerves.  patches  that  can  be  identified 

with  the  tendon  or  aponeur- 
osis of  a  muscle  which,  on 
inquiry,  will  be  found  to 
have  been  hardly  worked. 
Goes  along  with  an  inherited  or  As  often  as  not  occurs  in  persons 
acquired    nervous    tempera-  with  no  special  neurotic  teu- 

meut,  which  is  obvious.  dency. 

Is  much  less  aggravated,  usually,      Is  inevitably,  and  very  severely, 
by  movement  than  myalgia  aggravated   by  every    move 

is.  ment  of  the  part. 

Is    at    first  accompanied  by    no     Distinguished  from  the  first,  by 
local  tenderness.  localized       tenderness       on 

pressure  as  well  as  on  move- 
ment. 
Points  douloureux,  when  estab-      Tender  points  correspond  to  ten- 
lislicd  at  a  later  stage,  corre-  dinous  origins  and  insertions 

spond   to  the  emergence  of  of  muscles, 

nerves. 
Pain    not    materially  relieved  by     Pain  usually  completely  and  ah 
any  change  of  posture.  ways    considerably  relieved 

by  full  extension  of  the  pain- 
ful muscle  or  muscles. 


DISEASES  THAT  RESEMBLE  NEURALGIA.  199 

The  treatment  of  myalgia  is  not  only  satisfactory  in  itself, 
but  often  affords,  in  its  results,  a  very  desirable  confirmation 
of  diagnosis. 

For  a  very  large  number  of  cases,  all  that  is  required  is  (a) 
to  put  and  keep  the  affected  muscle  in  a  position  of  full  exten- 
sion, which  is  only  to  be  changed  at  somewhat  rare  intervals; 
(6)  to  cover  the  skm  all  over  and  round  it  with  spongio-piline, 
so  as  to  maintain  a  perpetual  vapor-bath ;  (c)  on  the  subsidence 
of  the  acutest  pain  and  tenderness,  to  complete  tlie  treatment 
by  one  or  two  Turkisli  baths,  to  be  taken  in  the  manner  that  I 
have  recommended  by  speaking  of  the  prophylaxis  of  neur- 
algia. 

When  treatment  such  as  this  cures  a  pain  which  was  greatly 
aggravated  by  muscular  movement,  we  may  be  sure  that  pain, 
was  myalgic  and  not  neuralgic. 

The  pain,  however,  is  not  unfrequently  rebellious  to  such 
simple  remedies  as  these,  more  especially  when  (as  in  pleui'ody- 
nia)  we  are  not  able  to  enforce  complete  physiological  rest  of 
the  part.  When  this  is  the  case,  we  shall  find  the  internal  use 
of  twenty  and  thirty  grain  doses  of  muriate  of  ammonia  by  far 
the  most  effective  remedy.  In  the  first  very  acute  stage  of  a 
severe  case  it  may  be  advisable  to  inject  morphia  hypodermic- 
ally;  but  this  is  seldom  necessary.  The  muriate-of -ammonia 
treatment  may  be  usefully  accompanied  by  prolonged  gentle 
frictions,  three  or  four  times  a  day,  with  a  weak  chloroform 
liniment. 

When  there  is  visibly  a  very  great  deficiency  in  the  general 
nutrition,  we  shall  often  fai  I  to  obtain  a  cure  until  we  have 
remedied  this  defect;  and  accordingly,  in  the  majority  of  cases 
of  half-starved  and  overworked  needle-women,  cobblers,  tailors, 
and  the  like,  who  present  themselves  in  the  out-patient  room, 
I  accompany  the  above-named  treatment  with  the  steady 
administration  of  cod-liver  oil  for  three  or  four  weeks  or  more. 
There  is  one  remedy  for  this  pain  which  I  have  myself  seen 
used  in  only  a  few  cases,  but  which  I  believe  promises  exceed- 
ingly well  for  the  treatment  of  obstinate  myalgia;  viz., 
acupuncture.  I  have  not  even  mentioned  it  as  a  remedy  for 
neuralgia,  for  I  believe  it  to  be  totally  useless  in  true  cases  of 
that  disease,  whether  applied  in  the  simple  form  or  in  that  of 
galvano-puncture.  I  think  very  differently  of  its  use  in 
myalgia ;  and  I  venture  to  believe  that  it  is  entirely  to  cases  of 
this  disease  that  the  exceedingly  interesting  observations  of 
Mr.  T.  P.  Teale,  in  a  recent  number  of  the  Lancet,  apply. 
Where  (after  the  usual  remedies  for  myalgia  have  been  applied) 
we  are  unable  to  get  rid  of  a  deep-seated  and  fixed  muscular 
pain,  I  believe  it  to  be  excellent  practice  to  plunge  two  or 
three  long  needles  deeply  into  the  muscle  near  its  tendinous 
attachment. 


200  SPINAL  IRRITATION. 

CHAPTER  II. 

SPINAL  IRRITATION. 

/  I  retain  this  pTii-ase,  not  because  it  is  an  absolutely  good  one, 
but  because  it  bas  become  so  familiar  that  it  is  dimcult  to  dis- 
pense witli  it.  We  have  talven  a  useful  step,  however,  in 
separating  the  true  neuralgias  from  the  somewhat  indefinite 
group  of  diseases  to  which  this  title  has  been  given,  i  thmk 
the  reader  who  has  carefully  studied  Part  I,  of  this  work  will 
not  deny  that  the  latter  disorders  present  a  very  cleai"  and 
definite  conunon  outhne  wlaich  distinguishes  them  essentially 
from  the  vaguer  affections  to  be  described  under  the  present 
heading. 

Spinal  irritation,  in  my  sense,  includes  all  those  conditions 
in  which,  without  any  special  mental  affection,  and  without 
anj  single  nerve  being  definitely  affected,  there  are  sensations 
varying  between  mere  cutaneous  tenderness,  often  of  a  largo 
and"  hregular  surface,  and  acute  pain  approaching  neuralgia  in 
character,  together  with  fixed  tenderness  of  certain  vertebras 
on  deep  pressure.  A  very  large  majority  of  the  phenomena 
are  such  as  would  be  popularly  included  (now  that  they  are 
known  not  to  be  of  an  inflammatory  character)  under  the  term 
"hysterical."  That  unhappy  word  ci'osses  our  path  at  every 
turn  in  a  most  embarrassing  m.anner,  and  vet  it  can  hardly  at 
present  be  said  that  we  could  afford  to  do  without  it. 

The  more  typical  cases  of  so-called  ' '  hysterical  hyper- 
sesthesia  "  present  the  following  phenomena:  Along  with  the 
general  symptoms  of  the  hysterical  temperament  (tendency  to 
causeless  "^depression,  variable  spirits,  sensation  of  globus,  semi- 
convulsive  attacks  terminated  by  the  discharge  of  a  gTeat 
quantity  of  pale,  limpid  urine)  there  is  commonly  a  marked 
superficial  tenderness  of  the  surface  every^-here.  and  an  exag- 
geration of  refiex  irritability.  The  general  tenderness  is  so  far 
merely  cutaneous  that  deep"  pressure  is  ordinarily  borne  better 
than  the  lightest  finger-touch.  But  besides  this  there  are 
usually  one  or  several  spots  in  which  the  tenderness  is  more 
profound  and  genuine.  There  is  almost  sure  to  be  some  point 
in  the  spinal  column  where  firm  pressure  not  merely  evokes  a 
complaint  of  pain,  but  also  induces  secondary  objective  phen- 
omena connected  with  distant  organs,  such  as  nausea  and 
vomiting  when  the  cervical  vertebra?  are  tender,  severe  gastric 
pain  when  the  dorsal  vertebra?  are  tender,  etc.  In  s  ach  cases 
there  is  not  only  spinal  tenderness,  but  very  usuahy  also  a 
well-marked  tenderness  in  the  epigastrium  and  the  left 
h^iDOchondrium,  the  trepied  h ysterique  of  Briquet.  The  reader 
must,  however,  be  warned  that  the  whole  of  these  three  tender 
points  may  be  merely  myalgic,  and  it  is  necessary  very  care- 


SPINAL  IRRITATION.  201 

fully  to  observe  ■whether  local  movements  do  or  do  not  seri- 
ously aggravate  the  pain  in  them.  And,  on  the  other  hand, 
the  spinal  tender  point  may  be  merely  the  ' '  point  apophysairc  " 
of  a  true  neuralgia  which  exhibits  no  other  symptoms  of  the 
so-called  hysteric  constitution. 

The  kind  of  hysteria  that  is  jomed  with  the  existence  of  fixed 
tender  spots  in  definite  points  of  the  vertebral  column  i"i  not 
commonly  distinguished  by  the  occurrence  of  cutaneous 
anaesthesia ;  but  those  writers  are  certainly  wrong  in  saying 
that  such  a  combination  never  takes  place.  I  have  seen  c;:azn- 
ples  of  the  most  marked  union  of  the  two  classes  of  symptoms 
in  the  same  person. 

These  cases  of  so-called  spinal  irritation  with  general  hys- 
teric manifestations  are  very  commonly  attended  with  par- 
oxysmal pains  that  approach  true  neuralgia  in  character .  Nor 
is  it  to  be  denied  that  we  sometimes  meet  with  the  combination 
of  general  hysteria,  spinal  tenderness  in  definite  points  (with 
secondary  spasmodic  or  paralytic  phenomena  always  following 
pressure  exerted  on  the  latter),  and  true  neuralgia  limited  to 
one  nerve.  But  the  more  typical  spinal  irritation  cases  are 
merely  complicated  with  a  tendency  to  vague  pains  which  are 
shifting  both  in  character  and  position,  not  with  definite 
unilateral  neuralgia  always  haunting  the  same  nerve  and 
exhibiting  more  or  less  of  the  same  type.  In  fact,  as  far  as  one 
can  judge  in  the  absence  of  any  pi'ecise  informiation  as  to  the 
condition  of  the  nervous  centers  in  such  cases,  it  would  seem 
likely  that  the  ordinary  cases  of  spinal  irritation  differ  from 
the  true  neuralgias  chiefly  in  this — that  the  injury,  or 
inherited  weakness  of  organization,  or  both,whicliisat  the  root 
of  the  malady,  is  at  once  slighter  in  degree,  and  spread  over  a 
larger  tract  of  the  nervous  centres,  than  that  which  produces 
a  true  neuralgia.  I  believe  that  Dr.  Radcliffe  is  right  in  sup- 
posing it  to  be  probable  that  a  blow  or  other  injury  to  the  back 
producing  general  spinal  shock,  is  the  original  but  unsus- 
pected cause  of  a  large  proportion  of  these  cases.  One  of  the 
most  jDerfect  examples  of  spinal  irritation  that  I  have  ever 
seen  (and  which  also  contrasts  keenly  with  the  commoner 
hysteric  alrections  on  the  one  hand,  and  the  true  neuralgise 
on  the  other)  was  that  of  a  girl  whom  I  examined  together 
with  Dr.  Walslie,  Dr.  Reynolds,  and  Dr.  Bridge.  This  young 
lady  was  a  most  intelligent  person,  and  not  in  the  slightest 
degree  inclined  to  the  apathy  and  idleness  so  often  seen  in 
hysterical  people.  She  bad  received  what  was  thought  at 
the  time  to  be  a  very  slight  contusion  in  a  railway  collision, 
in  which,  however,  her  sister,  who  was  in  the  same  carriage, 
had  been  severely  injured.  She  nursed  this  sister  assiduously, 
and  it  was  not  till  three  or  four  months  later  that  her  own 
health  began  to  fail  seriously  ;  but  she  then  became  anaemic 
and  extremely  depressed .    About  six  months  after  the  acci- 


202  SPINAL   IRRITATION 

dent  it  T\ras  quite  casually  discovered  tliat  there  "was  a  spot  over 
tLe  lowest  cervical  vertebra,  pressure  on  -wliicb.  gave  lier  exqui- 
site pain  and  a  sensation  of  extreme  nausea  ;  and  the  yevy 
curious  observation  Avas  made  that  such  pressure  instantane- 
ously produced  extinction  of  the  rig'ht  pulse,  the  left  pulse 
remainmg  unaltered.  In  this  case  it  cannot  be  doubted  that 
a  serious  shock  had  been  communicated  to  a  lateral  segment  of 
the  cord  involving  chieHj"  the  vasomotor  nerve  ilbres,  in  -^vhich 
probably  some  decided  material  lesion  had  been  gradually  set 
up  ;  and  besides  this  there  was  probably  slighter  damage  to 
the  spinal  cord  generally",  as  there  was  great  general  feebleness 
of  movement,  though  no  actual  paralysis  of  the  limbs. 

Along  vrith  the  phenomena  of  fixed  spinal  tenderness,  "with- 
out distinct  neuralgia  of  any  particular  nerve,  "we  not  unfre- 
quently  observe  the  development  of  more  or  less  decided  ten- 
derness of  some  of  the  internal  surfaces  of  the  body.  I 
have  recently  had  under  my  care  a  young  woman  in  whom 
a  very  tender  point  was  developed  over  the  second  cervical 
vertebra,  and  who  suffered  from  such  persistent  tenderness  of 
the  whole  posterior  i^art  of  the  pharynx,  that  I  was  for  some 
time  seriously  apprehensive  of  the  existence  of  spinal  caries 
and  post-pharyngeal  abscess.  The  general  character  of  her 
symptoms,  however,  induced  me  to  hope  that  the  case  was  one 
of  spinal  irritation  merely,  and  the  event  proved  that  this  was 
the  case,  for  under  the  use'of  iron  and  small  doses  of  strychnia 
she  recovered  completely  in  about  three  weeks  In  another 
patient  who  came  under  my  care  about  twelve  months  ago, 
there  was  extraordinary  sensitiveness  of  the  gastiic  muco"as 
membrane,  causing  exquisite  pain  after  she  had  eaten  almost 
any  thing  :  there  was  only  occasional  vomiting,  however, 
and  there  had  never  been  any  haemorrhage,  so  that  the  evi- 
dence for  gastric  ulcer,  which  I  otherwise  inclmed  to  think 
existed,  was  insufficient.  I  discovered  that  pressure  on  the 
third  or  the  fourth  dorsal  vertebra  gave  great  pain,  and  pro- 
duced a  strong  inclination  to  vomit  ;  this  made  it  probable 
that  the  affection  was  spinal,  and  accordingly  all  treatment 
addressed  to  the  stomach  was  abandoned.  Flying  blisters  to 
the  neighborhood  of  the  painful  spinal  points  quickly  relieved 
all  the  symj)toms. 

Another  distressing  class  of  symptoms,  which  is  very  cora- 
monly  observed,  in  connecti(ni  with  these  cases  of  spinal  u'ri- 
tation,  is  that  of  abnormal  arterial  pulsations  :  I  am  not  sure 
whether  even  severe  neuralgia  produces  more  distress  than 
does  this  pulsation.  I  have  repeatedly  seen  abnormal  pulsa- 
tion of  the  carotids  in  coimection  with  fix;ed  tender-points  over 
the  cervical  or  the  upper  dorsal  vertebrae  ;  and  still  more  com- 
monly pulsation  of  the  abdominal  aorta  in  connection  with 
tenderness  over  one  or  two  of  the  upper  dorsal  vertebrae. 
Spasmodic  cough  and  spasmodic  dyspnoea  frequently  accoiu-- 


SPINAL  IRRITATION.  203 

pany  tenderness  of  points  in  the  upper  half  of  the  spinal 
column  ;  and  in  one  instance  I  have  seen  pressure  on  the 
lowest  cervical  vertebrse  })roduce  a  paroxysm  which  looked 
alarmingly  like  angina  pectoris.  A  case  of  singularly  pro- 
longed and  obstinate  spasinodic  hiccough  which  came  under 
my  notice  was  distinguished  by  the  presence  of  a  fixed  tender 
spot  over  the  third  dorsal  vertebra . 

Prolonged  spastic  contraction  of  voluntary  muscles,  going 
on,  sometimes  for  weeks,  and  even  months,  is  a  phenomenon 
that  has  often  been  observed ;  it  may  attack  the  arm  only,  or 
may  affect  all  the  limbs,  and  the  muscles  of  the  trunk  and  of 
the  neck :  it  is  for  the  most  part  symmetrical,  but  is  occasion- 
ally unilateral.  It  begins  in  the  extremities,  and  is  very  com- 
monly limited  to  them  ;  it  is  much  more  gentle  than  tetanic 
spasm,  and  is  also  painless,  or  nearly  so ;  but  the  contraction 
is  often  strong  enough  to  resist  very  vigorous  efforts  at  arti- 
ficial extension. 

Paralyses,  both  of  bowel  and  bladder,  have  been  recorded 
among  the  occasional  phenomena  of  spinal  irritation  with 
fixed  tender  jDoints  ;  but  I  cannot  say  that  I  have  ever  seen 
such  an  occurrence.  On  the  whole,  I  must  say  that  by  far  the 
most  frequent  phenomena  of  spinal  irritation  that  I  have  seen 
have  been  somewhat  diffuse  cutaneous  or  mucous  tenderness 
and  irritability  (without  acute  pain)  and  the  presence  of  tor- 
mentating  arterial  throbbings;  also  a  marked  tendency  to 
aggravation  of  some  symptoms,  especially  the  gastric,  when 
firm  pressure  is  made  upon  the  tender  spinal  points.  For  a 
further  and  fuller  account  of  the  phenomena  of  spinal  irrita- 
tion I  may  refer  the  reader  to  the  able  article  of  Dr.  Eadcliffe,* 
and  the  work  of  the  brothers  Griffin,  already  quoted ;  adding 
the  suggestion,  however,  that  both  these  authorities,  and 
especially  the  Griffins,  appear  to  me  not  to  draw  a  sufficiently 
clear  distinction  between  the  class  of  cases  that  I  have  been 
attempting  to  describe  and  the  true  neuralgias. 

After  what  has  been  said,  there  is  no  need  to  draw  out  a 
formal  list  of  the  points  of  diagnosis  between  spinal  irritation 
and  neuralgia.  It  must  be  admitted,  moreover,  that  the  two 
forms  of  diseases  have  a  strong  connection  in  the  fact  that 
they  are  each  of  them  most  frequently  developed  in  the 
descendants  of  neurotic  families .  It  is  by  the  more  general- 
ized character  of  the  symptoms,  and  the  absence  of  the  ten- 
dency to  perpetual  recurrence  of  paroxysmal  pain  in  one 
definite  nerve,  that  spinal  irritation  is  mainly  distinguishable 
from  true  neuralgia.  I  may  add  that  there  is  a  marked  dis- 
tinction, also,  in  the  results  of  treatment. 

The  treatment  of  spinal  irritation  is,  it  must  be  confessed 
still  in  an  unsatisfactory  position;  and    I  believe  that  a  good 

*Reynokls's  "  System  of  Medicine,"  vol.  ii.,  Art.  "  Spinallrritation," 


204  SPINAL  IRRITATION. 

deal  of  unnecessary  discotlragement  has  been  occasioned  to 
physicians  by  their  failures  to  cure  supposed  neuralgias  which 
really  belonged  to  the  spuial  irritation  class.  I  would  assur- 
edly by  no  means  assert  tliat  genuine  neuralgia  is  not  fre- 
quently intractable,  or  even  incurable ;  but  it  is  certamly  much 
more  curable  than  spinal  irritation;  and  for  this  reason, 
mainly  as  I  believe — that  there  is  much  more  possibility  of 
aiming  our  remedies  at  tlie  actual  seat  of  tlie  disease.  On 
the  other  hand,  in  spinal  irritation  we  are  confused  and  dis- 
tracted with  a  variety  of  phenomena  for  which  even  the  most 
subtle  analysis  will  frequently  fail  to  trace  a  common  origin. 
It  is  true  that  the  existence  of  definite  tender  spots  in  the  spine 
apparently  suggests  a  strictly  local  application  of  remedies ; 
and  it  true  also  that  medication  based  upon  this  fact  is  some- 
times very  effective ;  but  this  is,  in  my  experience,  only  an 
occasional  result,  and  the  practitioner  who  trusts  to  local 
measures  will  frequently  be  disappointed.  And,  on  the  other 
hand,  the  general  tonic  treatment,  and  the  use  of  special  medi- 
cines, like  quinine  and  arsenic,  or  the  hypodermic  injection  of 
morphia  oratropia,  have  nothing  like  the  extensive  utility  in 
the  treatment  of  spinal  irritation  that  they  possess  in  that  of 
true  neui'algia.  Of  internal  remedies,  by  far  the  most  useful 
in  my  hands  have  been  sesquichloride  of  iron  with  small 
doses  of  strychnia,  and  the  milder  vegetable  bitters,  especially 
calumba. 

There  is  one  special  phase,  however,  of  spinal  irritation 
which  is  very  araenable  to  the  direct,  treatment,  viz. ,  cutane- 
ous and  mucous  tenderness.  Whatever  the  ''  hyperaesthetic  " 
part  is  within  reach,  so  that  we  can  apply  Faradization, 
we  can  almost  certainly  eradicate  the  morbid  sensibility  very 
quickly.  The  secondary  current  of  an  electro-magnetic  or 
volta-electric  induction  apparatus  is  to  be  employed ;  the  con- 
ductors should  be  of  dry  metal  and  the  negative  one,  which 
is  to  be  applied  to  the  painful  surface,  should  be  in  the  form  of 
the  wire  brush.  The  positive  pole  is  to  be  placed  on  some 
indifferent  spot,  and  the  negative  is  to  be  stroked  briskly  back- 
v/-ard  and  forward  over  the  sensitive  skin,  a  pretty  strong  cur- 
rent being  employed.  The  process  is  painful  so  much  so  that 
it  will  often  be  advisable,  Vv^ith  delicate  patients,  either  to 
administer  chloroform  or  to  inject  morphia  subcutaneously 
before  the  Faradization.  A  very  few  daily  sittings  of  four  or 
five  minutes  length  will  generally  remove  the  morbid  tender 
ness  completely.  Where  the  tender  part  is  within  one  of  the 
cavities,  at  the  rectum,  bladder,  vagina,  or  pharynx,  we  must 
of  course  use  a  solid  negative  conductor  of  appropriate  form, 
and  must  content  ourselves  with  applying  it  steadily  to  one 
point  after  another  of  the  sensitive  surface. 

The  fact  that  Faridization  proves  so  remarkably  useful,  in 
these    cases   of    spinal    irritation  with   diffuse  cutaneous  or 


SPINAL  IRRITATION.  205 

mticous  tenderness,  is  in  itself  a  strong  diagnostic  between  this 
sort  of  affection  and  the  true  neuralgise,  which,  as  I  have  stated 
are  seldom  benefited,  and  are  often  made  worse,  by  the  inter- 
rupted current,  though  the  constant  current  frequently  miti- 
gates or  cures  tliem. 

Sometimes  where  it  is  not  possible  to  apply  the  remedy 
directly  to  the  sensitive  surface,  we  may  nevertheless  do  great 
good  by  sending  the  interrupted  current  through  it.  Tlius,  in 
gastric  sensitiveness  connected  with  spinal  tenderness  in  the 
upper  dorsal  region,  I  have  seen  very  great  relief  afforded  by 
sending  a  current  from  the  positive  pole,  placed  on  the  tender 
ve'rtebras,  to  a  broad,  negative  conductor  placed  on  the  epigas- 
trium. And  similarly,  I  have  seen  an  acutely  sensitive  condi- 
tion of  the  neck  of  the  bladder  greatly  soothed  by  the  passage 
of  a  current  from  a  painful  lumbar  vertebra  to  the  perinaeum 
immediately  behind  tlie  scrotum. 

Undoubtedly,  however,  the  more  serious  cases  of  spinal  irri- 
tation will  yield  only  (if  they  yield  at  all)  to  a  prolonged 
treatment  in  which  very  skilful  use  is  made  of  general  hygienic 
measures,  and  especially  of  morbal  influences.  As  the  brotliers 
Griffin  long  ago  pointed  out,  although  rest  is  useful  in  the 
early  stages  of  this  malady,  if  the  disease  does  not  quickly 
yield  to  this  and  to  appropriate  tonic  medication,  and  perhaps 
local  applications  to  the  spine,  it  will  not  do  to  keep  the 
patient  recumbent  and  confined  to  the  house ;  on  the  contrary 
at  whatever  cost  of  immediate  discomfort,  he  (or  she  for  these 
patients  are  by  far  the  most  frequently  females)  must  be 
roused  up,  and  persuaded  or  compelled  to  take  out-door  exer- 
cise, and  if  possible  to  travel,  and  divert  the  mind  by  complete 
change  of  scene.  When  such  expensive  remedies  are  out  of 
the  question,  it  seems  better  that  patients,  even_  seemingly 
very  feeble,  should  take  to  their  ordinary;  avocations  in  life 
again,  and  fight  down  the  tendency  to  invalidism.  But  of 
course,  the  decision  on  sucli  a  point  must  rest  with  the  tact  and 
judgment  of  the  practitioner  in  each  individual  case,  for  there 
are,  doubtless,  instances  in  which  the  attempt  to  carry  out 
such  a  plan,  even  moderately,  would  break  down  the  remaining 
strength,  and  make  matters  worse  than  they  were  before. 

In  the  worse  case  of  spinal  irritation  that  I  ever  saw,  that  of  a 
young  lady,  aged  twenty-eight,  there  were  pronounced  anaemia 
and  general  feebleness,  the  true  hysteric  trepied  of  tender 
points,  painful  irritability  of  the  stomach,  which  baffled  all 
medical  advisers  and  resisted  almost  every  posible  form  of  tonic 
and  nervine  medicines,  counter-irritation  to  the  spine,  and,  in 
fact  every  thing  that  one  dared  attempt  with  so  feeble-looking 
a  patient,  but  at  once  cleared  up  and  was  quite  cured  after 
marriage.  And  there  can  be  no  question  that  a  very  large  pro- 
portion of  these  cases  in  single  women  (who  form  by  far  the 
greater  number  of  subjects  of  spinal  irritation)  are  due  to  this 


206  SPINAL  IRRITATION. 

conscious  or  ■unconscious  irritation  kept  up  by  an  unsatis- 
fied sexual  want.  In  some  patients  there  cannot  be  a  doubt 
that  thi?  condition  of  things  is  mdefinitely  aggravated  by  the 
practice  of  self  abuse ;  but  it  would  be  most  unjust  to  think  that 
this  is  a  necessary  element  in  the  causation ;  on  the  contrary, 
it  is  cei'tain  that  very  many  young  persons  (women  more  espec- 
ially) are  tormented  by  the  irritability  of  the  sexual  organs 
without  having  the  least  consciousness  of  sensual  desire,  and 
present  the  sad  spectacle  of  a  vie  manquee  without  ever  know- 
ing the  true  source  of  the  misery  which  incapacitates  them 
for  all  the  active  duties  of  life.  It  is  a  smgular  fact,  that  in 
occasional  instances  one  may  even  see  two  sisters  inheriting 
the  same  kmd  of  nervous  organization,  both  tormented  with 
the  symptoms  of  spmal  irritation,  and  both  probably  suft'er- 
ing  from  repressed  sexual  function,  but  of  whom  one  shall 
be  pvire-minded  and  entu'ely  unconscious  of  the  real  source  of 
her  troubles,  while  the  other  is  a  victim  to  conscious  and  fruit- 
less sexual  irritation. 

I  have  already  causually  alluded  to  the  danger  of  mistaking 
mere  myalgia  for  spinal  irritation  and  must  again  enforce  this 
consideration  upon  the  readci*  Mj^algic  tender  points  in  the 
region  of  the  s^jine  are  common  enough ;  and  it  would  be  easy 
without  careful  attention,  to  mistake  them  for  the  deeper- 
seated  vertebral  tenderness  which  is  truly  characteristic  of 
spmal  u'ritation.  Hence  the  utmost  care  must  be  taken  to 
ascertain  the  true  histoiy  of  the  commencement  of  the  disorder 
whether  it  succeeded  to  great  and  long  continued  fatigue  of  par- 
ticular sets  of  muscles,  and  whether  it  is  specially  aggravated  by 
contractions  of  those  muscles,  and  relieved  by  then'  full  exten- 
sion. The  differences  of  treatment  which  depend  on  the  diag- 
nosis are  too  obvious  to  need  dwelling  upon. 

Tiie  question  of  administering  remedies  with  the  direct 
intention  of  procuring  sleep,  for  patients  suffering  from 
spinal  irritation,  often  becomes  an  impoi'tant  and  a  very  difii- 
cult  one.  It  is,  for  the  most  part,  highly  objectionable  to  com- 
mence the  use  of  such  remedies ;  and  yet  sleeplessness  is  a  very 
distressing  symi)tom  with  many  patients,  and  is,  of  course  in 
itself  exhausting  and  deleterious .  For  as  long  as  we  possibly 
can,  we  should  content  ourselves  with  efforts  to  produce  sleep 
by  the  timely  administration  of  nourishment.  The  same  gen- 
eral rule  of  a  very  generous  (though  not  very  stimulating)  diet 
to  be  enforced  as  carefully  as  in  the  case  of  sufferers  from  neu- 
ralgia. But  it  is  especially  advisable  in  spinal  irritation ;  that 
the  patient  should  take  some  food  shortly  before  bedtime :  and  it 
is  well,  also  to  place  food  within  reach  at  the  bedside,  so  that  if 
he  wakes  up  he  may  take  some.  If,  however,  we  are  abso- 
lutely driven  to  employ  hj^-piio^jtics,  we  must  commence  with 
the  very  mildest.  The  popular  remedy  of  a  pillow  stuffed 
with  hops  will  sometimes  suflB.ce ;  and  a  better  way  of  admin- 


THE  PAINS  OF  HYPOCHONDRIASIS.  207 

isteriiig  the  volatile  principle  of  hops  is  to  scatter  a  few  hops 
on  hot  water  in  an  inhaler,  and  let  the  patient  breathe  the 
steam.  Hot  foot-baths,  with  mustard,  are  also  very  useful. 
If  these  fail,  chloral,  in  moderate  doses  is  probably  the  best 
and  safest  remedy,  and,  Avith  care  not  to  give  too  much,  we  may 
go  on  using  the  same  dose  without  increase  for  a  good  many 
times. 


CHAPTER  in. 

THE  PAINS  OF    HYPOCHONDRIASIS. 

There  is  perhaps  nothing,  in  the  whole  range  of  practical 
medicine,  more  diihcult  to  seize  with  clear  comprehension,  and 
picture  to  the  mind  with  accuracy,  than  the  group  of  pseudo- 
neuralgiae  which  belong  to  the  domain  of  hypochondriasis. 
They  are  among  the  most  indefinable,  and  at  the  same  time 
the  most  intractable,  of  nervous  affections. 

To  understand  v/hat  hypochondriac  pains  are,  we  must  first 
be  familiar  with  the  general  character  of  the  hypochondriacal 
temperament,  for  the  pains  are  otily  a  subordinate  and  ever- 
varying  phenomena  of  the  general  disease. 

Hypochondriasis  is  not  insanity,  if  by  insanity  we  mean 
intellectual  perversion  dependent  mainly  or  entirely  on  the 
state  of  the  higher  nervous  centres.  But  it  is  closely  allied  to 
insanity  in  its  phenomena,  only  that  these  are,  as  it  were, 
manifested  in  a  scattered  form,  imequally  distributed  over  the 
whole  central  nervous  system,  and  especially  affecting  the 
spinal  sensory  centres.  And  its  radical  relationship  to  true 
insanity  is  strongly  indicated  by  the  fact  that  the  sufferers 
from  hypochondriasis  are  nearly,  if  not  quite,  always  members 
of  families  in  which  distinct  insanity  has  shown  itself ;  indeed, 
more  often  than  not,  of  families  which  have  been  strongly 
tainted  in  this  way.  In  the  majority  of  instances  there  are 
psychical  peculiarities  of  a  marked  kind  which  accompany  or 
precede  the  development  of  the  abnormal  sensations  which 
form  the  especial  torment  of  hypochondriacs.  Without 
apparent  cause,  they  begin  to  evince  a  heightened  self-feeling 
and  an  anxious  concentration  of  their  thoughts  upon  the  state 
of  one  or  more  of  their  bodily  organs.  Or  it  may  be  that, 
before  any  such  definite  bias  is  given  to  their  thoughts,  they 
simply  become  less  sociable  and  more  self-centred,  and  are  sub- 
ject to  fits  of  indefinite  and  inexplicable  depression,  or  at  least 
to  great  variability  of  spirits.  But  before  long  they  begin  to 
experience  definite  morbid  sensations,  most  commonly  con- 
nected with  the  digestive  organs,  and  very  often  accompanied 
by  positive  derangement  of  digestion  of  an  objective  character ; 


208  THE  PAINS  OF  HYPOCHONDRIASIS, 

sucli  as  flatulence,  sour  eructation,  spasmodic  stomacla-paia, 
etc.  Along  with  these  phenomena,  or  soon  afterward  (and  not 
un frequently  before  the  patient  has  acquired  tlaat  intensity  of 
morbid  conviction  of  his  having  some  si^ecial  disease  Avhich  is 
afterward  so  marked  a  peculiarity  of  his  mental  state),  he  very 
often  becomes  the  subject  of  the  kind  of  pains  which  it  is  the 
special  purpose  of  this  chapter  to  describe. 

The  pains  of  hypochondi'iasis,  when  they  assume  any  more 
definite  form  than  that  of  mere  dysjieptic  uneasiness,  j) resent 
many  analogies  with  neuralgia.  They  are  not,  usually,  periodic 
in  any  regular  manner,  but  they  have  Jie  same  tendency  to 
complete  intermission,  and  they  frequently  haunt  some  one  or 
more  definite  nerves  for  a  considerable  period  of  time.  Of  all 
nerves  that  are  liable  to  this  kind  of  aiiections  the  vagus  is 
undoubtedly  the  most  suscex^tible ;  hypochondriac  patients 
very  frequently  complain  of  pseudo-anginoid  and  pseudo-gas- 
tralgic  pains ;  next  in  frequency  are  nervous  pam  in  the  region 
of  tiie  liver,  or  m  the  rectum  or  bladder.  The  main  distinc- 
tions by  Avhich  they  are  se^sarable  from  true  neuralgia  are  two : 
in  the  first  place,  the  character  of  the  pain  nearly  always  is 
more  of  the  boring  or  burning  kind  than  of  the  acutely  darting 
sort  which  is  most  usual  in  true  neuralgia ;  and,  secondly,  the 
influence  of  mental  attention  in  aggravating  the  pain  is  far 
more  pronounced  than  in  the  latter  malady ;  indeed,  it  is  often 
possible,  by  merely  engaging  the  patient  in  conversation  on 
other  topics,  to  cause  the  pain  to  disappear  altogether  for  the 
time.  But  in  hypochondriasis  it  is  not  often  that  we  are  left, 
for  any  long  time,  to  these  means  of  di?.gnosis  only ;  the  special 
character  of  the  disease  is  that  the  morbid  sensations  sliift  from 
one  place  to  another,  in  a  manner  that  is  quite  unlike  that  of 
the  true  neuralgias.  The  patient  who  to-day  complains  of  the 
most  severe  gastralgia,  or  liver-pain,  will  co-morrow  place  all 
his  sufferings  in  the  cardiac  region,  or  in  the  rectum,  or  Avill 
complain  of  a  deep  fixed  pain  withm  his  head;  and  these 
changes  are  often  most  rapid  and  frequent.  Frequently  there 
are  also  peculiar  skin  sensations,  which  usually  approach 
formication  in  type,  and  these,  like  the  pains,  ai'e  apt  to  shift 
with  rapidity  from  one  part  of  the  body  to  another.  Later  on 
m  the  disease,  especially  in  those  worst  cases  Avhich  approach 
most  closely  to  the  type  of  true  insanity,  there  are  often 
hallucinations  of  a  peculiar  and  characteristic  nature,  such  as 
the  conviction  of  the  patient  that  he  has  some  animal  inside 
him  gnawing  his  vitals,  that  he  is  made  of  glass  and  in  con- 
stant danger  of  being  broken,  and  a  variety  of  sunilar  absurdi- 
ties. In  short,  it  is  not  the  full-developed  cases  of  hypo- 
chondriasis that  need  puzzle  us,  these  are  usually  distinct 
enough;  but  the  earlier  and  less  characteristic  stages  in  Avhich 
pain  may  be  nearly  the  onlv  symptom  that  is  particularly 
prominent. 


THE  PAINS  OF  HYPOCHONDRIASIS,  209 

In  hypochondriasis,  as  in  hysteria,  there  is  often  great  sen- 
sitiveness of  the  surface ;  and,  as  in  hysteria,  tlais  sensitiveness 
IS  found  to  be  very  superficial,  so  tliat  a  liglit  touch  often 
hurts  more  tlian  firm,  deep  pressure.  As  in  liysteria,  too,  tlie 
tenderness  is  a  phenomenon  so  greatly  affected  by  the  mind, 
that,  if  we  can  divert  the  patient's  attention  for  a  moment,  he 
will  let  us  toucii  him  anywhere,  without  noticing  it  at  all. 

It  is  a  marked  peculiarity  of  hypochondriasis  tliat  it  is  far 
more  common  in  men  than  m  women;  a  relation  which  is  pre- 
cisely the  opposite  to  that  which  rules  in  neuralgia.  Hypochon- 
driasis is  also  pre-eminently  a  disease  of  adult  middle  life ;  it  is 
scarcely  ever  seen  m  youth,  except  as  the  result  of  excessive 
masturbation  acting  on  a  temperament  hereditarily  predisposed 
to  insanity. 

The  results  of  treatment  frequently  assist  our  diagnosis  in 
difficult  cases.  Almost  any  medicine  will  relieve  the  pains  of 
the  hypochondriac  for  a  tune,  and  it  is  generally  far  easier 
to  do  him  good,  temporarily,  than  it  is  to  relieve  a  neuralgic 
patient ;  but,  en  revanche,  every  remedy  is  apt  to  lose  its  affect 
after  a  little  while.  The  only  chance  of  producing  permanent 
benefit  in  hypochondriasis  is  by  the  judicious  combination  of 
remedies  that  remove  symiotoms  (especially  dyspepsia,  flatu- 
lence, etc.),  which  mischievously  engage  the  patient's  mmd, 
with  general  tonics,  and,  above  all,  which  such  alterations  in 
the  patient's  habits  of  daily  life  as  take  him  out  of  himself  and 
compell  him  to  interest  himself  in  the  affairs  of  the  world 
around  him.  And,  after  all,  our  best  efforts  will  frequently 
lead  to  nothing  but  disappointment. 

It  is  notoriously  the  fact  that  hypochondriasis  especially 
affects  the  rich  and  idle  classes ;  but  it  would  be  a  great  mistake 
to  suppose  that  it  never  attacks  the  poor  or  the  hard  worked; 
only,  in  the  latter  instances,  it  apparently  needs,  for  it  develop- 
ment, the  existence  of  strong  family  tendencies  to  neurotic 
disease,  and  especially  to  insanity.  Among  the  numerous 
debilitated  persons  who  attend  the  out-patient  rooms  of  our 
hospitals  we  every  now  and  then  encounter  as  typical  a  case  of 
hypochondriasis  as  could  be  found  even  among  the  rich  and 
gloomy  old  bachelors  Avho  haunt  some  of  our  London  clubs. 
I  have  one  such  patient  under  my  care  now,  who  has  been  a 
repeated  visitor  at  the  Westminister  Hospital  during  many 
years:  he  has  had  pseudo-neuralgic  pains  nearly  everywhere 
at  diff'erent  times  ;but  his  most  complaint  has  been  of  pain  in  the 
groin  and  scrotum  of  the  right  side.  The  existence  of  what 
seemed,  at  first,  like  the  tender  points  of  lumbo-abdominal 
neuralgia,  at  one  time  led  me  to  believe  it  was  a  case  of  that 
affection  ;  but  I  was  soon  undeceived  by  .finding  that  the  ten- 
derness did  not  remain  constant  to  the  same  points,  but  shifted 
about.  This  man  has  professed,  by  turns,  to  derive  benefit 
from  nearly  all  the  drugs  in  the  Pharmacopoeia ;  but  the  only 
14 


210  THE    PAINS    OF   LOCOMOTOR   ATAXY. 

reraedies  that  have  done  liim  good,  for  more  than  a  day  or 
two  at  a  time,  have  been  valerian  and  assafoetida,  with  the 
prolonged  use  of  cod-liver  oil.  He  will  never  be  really  cured; 
and  I  suspect  that  the  secret  of  his  maladies  is  an  inveterate 
habit  of  masturbation  acting  on  a  nervous  system  hereditarily 
predisposed  to  hypochondriasis. 

Sometimes  it  happens  that  the  starting-point  of  hypochond- 
riac pains,  simulating  neuralgia,  is  a  blow,  or  other  bodily 
injury  acting  on  a  predisposed  nervous  system .  Another  of 
my  patients  at  the  Westminster  Hospital  was  a  policeman, 
who  had  received  a  severe  kick  in  the  groin ;  he  suffered  pains 
which  at  first  seemed  to  wear  all  the  characters  of  true  neu- 
ralgia in  the  pudic  nerve,  but  afterward  shifted  to  other  places 
and  exhibited  all  the  intractability  of  hypochondi'iasis ;  the 
patient  also  developed  the  regular  appearance  and  the  charac- 
teristic hallucinations  of  the  latter  disease.  On  the  last 
occasion  when  I  saw  him,  he  struck  me  as  likely  to  become 
really  insane,  in  the  melancholic  form  ;  and  the  probability  is 
that  the  casualty  which  he  suffered  was  only  accidentally  the 
starting-point  of  a  malady  which  was  inherent  in  him  since 
birth,  and  would  have  been  developed,  in  any  case,  at  some 
period  of  his  life. 


CHAPTER  IV. 

THE  PAINS  OF  LOCOMOTOR  ATAXY. 

Considermg  the  vast  amount  that  has  been  written  about 
this  disease  during  the  last  few  years,  it  might  bethought 
superfluous  for  me  to  give  any  description  of  its  general  fea- 
tures. But  it  unfortunately  happens  that  there  is  still  great 
divergence  of  opinion  among  authorities  as  to  the  true  limita- 
tion of  the  grou"  of  cases  that  can  properly  be  ranked  under 
this  title,  and,  indeed,  as  to  the  propriety  of  employing  the  title 
at  all.  The  phrase  ataxic  locomotrice  progressive,  as  every 
one  knows,  was  applied  by  Duchenne  de  Boulogne  to  a  class 
of  cases  which  really  only  form  a  subdivision  of  the  group 
known  under  the  older  title  of  tabes  dorsalis  and  the  most 
advanced  G-erman  pathologists  maintain  that  the  old  word 
was  better,  and  that  Duchenne  was  altogether  wrong  in  mak- 
ing the  one  symptom,  ataxy  of  locomotion,  the  bases  of  a  new 
phraseology  f  more  especially  as  his  theory  as  to  the  seat  of 
the  morbid  changes  was  undoubtedly  erroneous. 

*  The  most  complete  and  careful  work  of  the  German  school,  on 
this  subject,  is  the  "  Lehre  vou  der  Tabes  dorsualis,"  of  E.  Cyoa 
(Berlin,  1867.) 


THE  PAINS  OF  LOCOMOTOR  ATAXY.  211 

In  this  country,  however,  there  is  as  yet  no  disposition  to 
give  up  the  phrase  locomotor  ataxy,  and  it  only  remains  to 
define  with  sufficient  care  the  class  of  cases  to  which  the  word 
is  here  meant  to  apply.  The  disease  is  understood  to  depend 
upon  a  degeneration  of  the  spinal  cord,  of  which  the  follow- 
ing description  is  given  by  Lockhart  Clarke  •*  "In  true 
locomotor  ataxy,  the  spinal  cord  is  invariably  altered  in  struc- 
ture. Its  membranes,  however,  are  semetimes  apparently 
unaffected,  or  affected  only  in  a  slight  degree  ;  but  generally 
they  are  much  congested,  and  I  have  seen  them  thickened  pos- 
teriorly by  exudations,  and  adherent,  not  only  to  each  other, 
but  to  the  'posterior  surface  of  the  cord.  The  posterior  col- 
umns, including  the  posterior  nerve-roots,  are  the  parts  of  the 
cord  which  are  chiefly  altered  in  structure.  This  alteration  is 
peculiar,  and  consists  of  atrophy  and  degeneration  of  the  nerve 
fibres  to  a  greater  or  less  extent,  with  hypertrophy  of  the  con- 
nective tissue,  which  give  to  the  columns  a  grayish  and  more 
transparent  aspect  ;  in  this  tissue  are  embedded  a  multitude  of 
corpora  amylacea.  Many  of  the  blood  vessels  that  travel  the 
columns  are  loaded  or  surrounded  to  a  variable  depth  by  oil- 
globules  of  various  sizes.  For  the  production  of  ataxy,  it  seems 
to  be  necessary  that  the  changes  extend  along  a  certain  length. 
from  one  to  two  inches  of  the  cord .  The  posterior  nerve- roots, 
both  within  and  without  the  cord,  are  frequently  affected  by 
the  same  kind  of  degeneration,  which  sometimes  extends  to  the 
surface  even  of  the  lateral  columns,  and  occasionally  along 
the  edges  of  the  anterior.  Not  unfrequently  the  extremity  of 
the  posterior  cornua,  and  even  deeper  parts  of  the  gray  sub- 
stance, are  more  or  less  damaged  by  areas  of  disintegration. 
The  morbid  process  appears  to  travel  from  centre  to  periphery, 
that  is,  from  the  spinal  cord  to  the  posterior  roots.  In  the 
cerebral  nerves,  on  the  contrary,  the  morbid  change  seems  to 
travel  in  the  opposite  direction,  that  is,  from  the  periphery 
toward  the  centres.  From  the  optic  nerves  it  has  been  found 
to  extend  as  far  as  the  corpora  geniculata,  but  seldom  as  far 
as  the  corpora  quadrigemina.  With  the  exception  of  the  fifth, 
seventh,  and  eighth  pair,  all  the  cerebral  nerves  have  occa- 
sionally been  found  more  or  less  altered  in  structure." 

The  symptoms  which  occur  in  cases  in  which  the  above  are 
the  morbid  appearances  found  after  death  are  (roughly  speak- 
ing) as  follows  :t  "A  peculiar  gait,  arising  from  want  of 
co-ordinating  power  in  the  lower  extremities,  a  gait  precipitate 
and  staggering,  the  legs  starting  inther  and  thither  in  a  very 
disorderly  manner,  and  the  heels  coming  down  with  a  stamp 
at  each  step." 


*  Lancet,  June  10,  1865.     (Comment  on  a  case  of  Dr.  J.  Hugh- 
lings  Jackson's.) 

f  Radcliffe,  in  "Reynold's  System  of  Medicine,"  vol  ii. 


212  THE  PAINS  OF  LOEOMOTOR  ATAXY. 

No  true  paralysis  in  the  lower  extremities  or  ekowhere. 
Characteristic  '^^uralgic  pains,  erratic  paroxysmal  in  tlie  feet 
and  legs  chiefly — XDain:;  of  n,  boring,  throbbing,  shooting  char- 
acter, like  those  caused  by  a  sharp  electric  shock. 

More  or  less  numbness,  m  the  feet  and  legs  chiefly,  in  all 
forms  of  sensibility,  excepting  that  by  which  differences  of 
temperature  are  recognized. 

Frequent  impairment  of  sight  or  hearing,  one  or  both. 

Frequent  trarsHory  or  permanent  strabismus  or  ptosis,  one 
or  both. 

No  very  obvious  paralysis  of  the  bladder  or  lower  bowel. 

No  necessary  impairment  of  sexual  power. 

Ko  tingling  or  kindred  phenomenon. 

No  marked  tremulous,  convulsive,  or  spasmodic  phenomena. 

No  marked  imiJairment  of  muscular  nutrition  and  irrita- 
bility. 

No  impairment  of  the  mental  faculties. 

( )ccasio'nal  mjection  of  the  conjunctiva,  with  contraction  of 
the  pupils. 

The  probable  limitation  of  the  distinctive  phenomenon  of 
locomotor  ataxy  (the  want  of  co-ordinating  motor  power)  to 
the  lower  extremities. 

The  above  description  includes  all  the  necessary  facts  for  the 
recognition  of  the  disease,  except  one,  namely,  that  the  use  of 
the  eyesight  is  always  needed  in  order  to  prevent  the  patient 
fro}n  falling  during  progression  ;  and  is  usually  necessary  even 
to  enable  him  to  stand  upright  without  falling. 

^-he  pains  of  locomotor  ataxy  are  early  phenomena  in  most 
cases,  and  they  are  usually  present,  more  or  less,  throughout 
the  course  of  the  disease. 

^J.^hey  are  often  preceded  by  strabismus,  with  or  without 
ptosis  ;  the  strabismus,  is  usually  accompanied  by  amblyopia. 
It  may  happen,  however,  that  neuralgic  pains  are,  for  a  con- 
siderable time,  tlie  only  noticeable  plienomena  ;  or  they  may 
be  attended  with  a  certain  amount  of  amsesthesia. 

The  most  frequent  type  of  the  pains  is  lancinating  or  stab- 
bing ;  they  are  like  violent  neuralgias  occurring  successively 
in  various  nerves  ;  shifting  about  from  one  to  another .  Some- 
times it  will  happen  that  the  pain  remains  fixed  to  one  par- 
ticular nerve  for  hours  together  ;  but  it  never  continues  long 
without  showing  the  characteristic  tendency  to  move  about. 
Most  commonly  our  diagnosis  is  soon  assisted  by  the  occur- 
rence of  a  greater  or  less  degree  of  ataxy.  But,  even  before 
the  wetting  in  of  definite  atactic  symptoms,  the  shifting  .  "^ar- 
acter  of  the  iDains,  and  the  development  of  a  very  noticeable 
am(  unt  of  ansesthesia,  together  with  the  absence  of  anything 
like  positive  motor  paralysis,  will  have  given  us  the  necessary 
dew. 

The  effect  of  treatment,  or  rather  its  want  of  effect,  usually 


THE  PAINS  OF  CEREBRAL  ABSCESS.  213 

affords  powerful  assistance  in  distinguishing  the  pains  of  loco- 
motor ataxy  from  tliose  of  true  neuralgia.  Even  where  the 
pain  has  been  fixed  for  some  hours  in  a  single  nerve,  and  has 
been  stopped  by  some  powerful  remedy  (such  as  hypodermic 
morphia),  it  will  be  apt  speedily  to  recur,  and  frequently  in 
some  quite  distant  nerve. 

Locomotor  ataxy  is  a  disease  affecting  chiefly  the  male  sex, 
and  occurring  in  the  immense  majority  of  cases  between  the 
thirty-fifth  and  the  fiftieth  year. 

Not  merely  is  it  strictly  limited  to  individuals  who  belong  to 
families  with  neurotic  tendencies,  but  it  is  itself  frequently 
seen  to  occur  in  several  members  of  the  same  family,  and 
sometioaes  of  the  same  generation.  When,  therefore,  we  meet 
with  neuralgic  pains  of  the  shifting  type  above  described,  it  is 
very  important  at  once  to  make  careful  inquiries  whether  any 
members  of  the  family  have  suffered  from  symptoms  of  ataxy 
going  on  to  a  fatal  result.  Otherwise,  we  might  be  the  more 
readily  deceived  into  the  idea  that  the  pains  were  merely  neu- 
ralgic, because  the  symptoms  of  the  disease  are  not  anfre- 
quently  provoked  by  such  causes  as  fatigue  and  exposure  to 
cold  or  wet,  which  are  also  very  ordinaiy  exciting  caases  of 
true  neuralgia. 


CHAPTER  V. 

THE  PAINS  OF    CEREBRAL  ABSCESS. 

Cerebral  Abscesses  is,  fortunately,  a  rare  disease;  but  the 
very  fact  of  its  rarity  makes  the  resemblance  of  the  pain  it 
causes  to  that  of  neuralgia  the  more  lilcely  to  lead  us  into  ser- 
ious errors.  We  are  a^Dt  to  forget  the  possibility  of  suppura- 
tion of  the  brain  on  account  of  its  infrequence. 

Pain  in  the  head  is  present  as  an  early  symptom  of  abscess 
m  the  brain  in  a  large  proportion  of  cases  in  vv^hich  there  is 
pain  at  all.  [Of  seventy-five  cases  of  cerebral  abscess  anal- 
yzed by  Gull  and  Sutton  (Reynolds's  "System  of  Medicine," 
vol.  ii.),  pain  was  a  symptom  in  thirty- riine,  and  most  fre- 
quently an  early  symptom.]  Many  cases  are  recorded  in 
which  it  preceded  every  other  morbid  sign  by  a  considerable 
period.  It  is  usually  more  or  less  paroxysmal,  often  strik- 
ingly so ;  in  the  latter  case,  it  bears  a  great  similarity  to  neu- 
ralgia. On  the  other  hand,  it  sometimes  takes  the  shape 
of  a  fixed  burning  sensation,  much  less  resembling  neu- 
ralgia. The  situation  of  the  pain  by  no  means  always,  nor 
even  usually,  corresponds  to  the    situation  of  the  cerebral 


214 


THE  PAINS  OF  CEREBRAL  ABSCESS. 


abscess ;  on  the  contrary,  abscess  in  the  cerebellum  has  often 
caused  pain  referred  to  the  anterior  part  of  the  head,  and  so 
on.  So  long  as  the  disease  remams  characterized  only  by 
pain,  more  or  less,  of  a  paroxysmal  character,  the  diagnosis 
must  be  very  uncertain ;  but  in  the  great  raajority  of  cases 
certain  more  distinctive  sjTnptoms  soon  become  superadded; 
either  convulsions  (sometimes  hemiplegic),  A^ertigo,  coma, 
paralysis,  vomiting,  or  a  combination  of  some  of  these. 

In  the  stage  in  wliich  there  is  as  yet  no  conspicuous  symp- 
tom but  severe  pain,  the  diagnosis  of  cerebral  abscess  from 
neuralgia  must  rest  on  the  following  points  of  contrast : 


Cerebral  Abscess. 

Often  occurs  secondarily  to  car- 
ies of  iuterual  ear,  and  puru- 
lent discbarge  the  result  of 
scarlet  fever,  measles,  etc., 
in  childhood. 

Frequently  follows  a  blow  or 
injury. 

No  true  "points  douloureux." 


Usually  the  pain  does  not  com- 
pletely intermit. 

Pain  often  excruciating  from  a 
very  early  period. 

Pain  often  limited  in  situation, 
seems  deep- seated,  though, 
as  often  as  not,  it  has  no 
relation  to  the  site  of  the 
abscess. 

No  well  localized  vaso-motor  or 
secretory  complications. 


Very    rare    in   old    age; 
usually  traumatic. 


then 


Relief  from  stimulant  narcotics 
very  transitory. 


neuralgia  of  Head. 
"Rarely  appears  before  puberty. 


Comparatively  seldom  caused  by 
blow,  or  other  external 
injury  or  caries  of  boue. 

If  severe,  soon  presents,  in  most 
cases,  the  ' '  points  doulou- 
reux." 

Intermissions  of  pain  complete, 
and  of  considerable  length. 

Pain  usually  not  verv  violent  at 
tirst. 

Pain  superficial ;  follows  distribu- 
tion of  recognizable  nerve- 
branches  belonging  to  the 
trigeminus  or  the  great  occipi- 
tal. 

Usually  there  are  lachrymation, 
congestion  of  conjunctiva, 
or  other  vaso-motor  and  sec- 
retory complications,  such 
as  are  described  in  Chapter 
III. 

Severe  and  intractable  neuralgia 
is  commonest  in  the  degen- 
erative period  of  life. 

Relief  from  opium,  etc.,  is  much 
more  considerable  and  per- 
manent. 


The  only  case  of  cerebral  abscess  that  I  have  personally 
seen,  in  which  tlie  above  points  of  distinction  v/ould  have  been 
insufficient,  was  thai  of  a  boy  of  sixteen,  in  whom  the  only  dis- 
coverable symptom,  for  nearly  three  months,  was  pain,  very 
strongly  re'sembhng  ordinary  migraine,  recurring  not  oftener 


PAINS  OF  ALCOHOLISM.  315 

than  once  in  ten  days  or  a  fortnight,  lasting  for  some  hours  at 
a  time,  and  nearly  always  ending  in  vomiting,  and  disappear- 
ing after  sleep.  At  the  end  of  the  three  months,  acute  pain  in 
the  left  ear  set  in,  and  this  was  followed,  soon,  hy  right  hemi- 
plega,  coma,  and  death.  It  was  then  discovered,  although  it 
had  formerly  heen  denied,  that  the  boy  had  sulfered  from  dis- 
charge from  the  left  ear,  following  a  febrile  attack  which  had 
been  marked  by  sore-throat,  and  followed  by  desquamation  of 
the  cuticle — evidently  scarlet  fever.  In  all  cases  of  severe 
pain  in  the  head,  it  is  a  golden  rule  to  inquire  most  carefully 
as  to  the  possible  existence,  present  or  past,  of  discharge  from 
the  ear,  or  other  signs  of  caries  of  the  temporal  bone ;  and, 
even  if  no  j)ositive  history  of  this  kind  be  given,  we  should 
still  regard  with  great  suspicion  any  case  in  which  there  has 
been  scarlet  fever  followed  by  deafness. 


CHAPTER  YI. 

PAINS  OF  ALCOHOLISM. 

A  very  important  class  of  pains,  which  are  occasionally 
confounded  with  true  neuralgias,  are  those  which  occur  in  cer- 
tain forms  of  chronic  alcoholism.  The  diagnosis  of  their  true 
nature  is  a  matter  of  the  utmost  consequence,  and  the  failure 
to  recognize  them  for  what  they  are  may  have  very  disastrous 
results.  It  is  a  curious  fact  that  this  consequence  of  chronic 
alcoholic  poisoning  has  been  entirely  overlooked  by  some  of 
the  best  known  writers  on  that  affection;  it  has,  however, 
been  described  by  Mr.  John  Higgmbottom,  and  also  by  M. 
Leudet. 

It  must  be  clearly  understood  that  the  i^ains  of  which  we  are 
now  to  speak  are  not  among  the  common  consequences  of 
chronic  excess  in  drink.  The  affections  of  sensation  which 
most  usually  occur  in  alcoholism  take  the  shape  either  of 
anaesthesia,  or  of  this  combined  with  anomalous  feelings  par- 
taking more  or  less  of  the  character  of  formication.  Chronic 
drinking  has  also  a  tendency,  in  its  later  stages,  when  the 
nutrition  of  the  nervous  centres  has  been  considerably  impaired 
by  the  habit,  to  set  up  true  neuralgia,  of  a  formidable  type,  in 
subjects  who  are  hereditarily  predisposed  to  neuroses.  But 
the  affection  of  which  I  now  speak  may  occur  at  any  stage 
except  the  very  earliest,  and,  though  often  severely  painful,  is 
essentially  different  both  in  its  seat  and  in  its  general  charac- 
ters, from  neuralgia  proper. 

The  earliest  symptoms  from  which  the  patient  usually  suffers 


216  PAINS  OP  ALCOHOLISM. 

in  these  cases  are  insomnia,  and  intense  depression  of  spirits, 
which,  however,  is  not  incompatible,  mdeed  is  frequently 
combined,  with  a  morbid  activity  and  restlessness  of  thought. 
There  is  generally  marked  loss  of  a^jpetile,  but  often  there  is 
none  of  the  morning  nausea  so  characteristic  of  the  common 
forms  of  alchohcism.  Nor  is  there,  ordinarily,  any  special 
unsteadiness  of  the  muscular  system.  The  X)ains  are  usually 
first  felt  in  the  shoulder  and  down  the  spine  ;  but  as  the  case 
progresses  they  especially  attack  the  wrist  and  ankles ;  and  it 
is  in  these  latter  situations  that  I  have  found  them  to  be  most 
decidedly  complamed  of.  Their  similarity  to  neuralgia  con- 
sists (a)  in  then'  somewhat  proxysnial  character ;  (&)  in  their 
frequently  recurring  at  about  the  same  hour  ot  the  day,  most 
commonly  toward  night ;  and  (c)  in.  then*  special  aggravation 
by  bodily  and  mental  fatigue. 

Their  differences  from  neuralgia  are  —(a)  that  they  never 
follow  the  coiU'se  of  a  recognizable  single  nerve ;  (6)  that  they 
are  nearly  always  present  in  more  than  one  lunb,  and  usually 
in  both  halves  of  the  body,  at  the  same  time;  and  (c) 
especially,  that  they  ai-e  far  less  promptly  and  effectually 
relieved  by  hypodermic  morphia  than  are  the  true  neuralgias ; 
indeed,  opiates  very  frequently  only  shghtly  alleviate  the  pain, 
while  they  excite  and  agitate  the  patient  and  render  sleep 
impossible.  On  the  contrary,  a  large  dose  of  wine  or  brandy 
will  never  fail  to  procure  temporary  comfort  and  induce  sleep, 
at  least  until  the  patient  reaches  an  advanced  stage  of  the  dis- 
order, and  is,  in  fact,  on  the  Yerge  of  delirium  tremens. 

I  am  not  quite  sure  that  I  am  right  in  believing  that  there  is 
a  special  physiognomy  for  this  form  of  chro}iic  alcoholism,  and 
yet  I  am  much  inclined  to  believe  that  there  is.  All  the 
patients  whom  I  have  seen  suffering  with  it  have  presented  a 
peculiar  brown  sallowness  of  face,  and  a  general  harsh  dry- 
ness of  the  skm,  which  has  usually  lost  its  natural  clearness, 
not  only  in  the  face,  but  even  more  remarkably  in  the  hands, 
which  are  so  dark-colored  as  to  appear  as  if  they  were  du-ty. 
There  is  usually  considerable  leanness  of  the  limbs,  and,  though 
the  abdomen  ma.y  be  somewhat  promment,  this  does  not  seem 
to  depend  much  on  the  presence  of  fat,  but  rather  on  relaxa- 
tion of  the  abdominal  muscles,  and  sometimes  flatulent  disten- 
tion of  the  stomach  and  intestines.  The  hands  are  usually 
hot,  sometuiies  quite  startlingly  so. 

Some  of  the  patients  suffer,  besides  the  pains  in  the  limbs 
(which  they  often  describe  as  resembling  the  feeling  of  a  tight 
band  pressing  severely  around  the  ankles  or  wrists),  from  fre- 
quent or  occasional  attacks  of  genuine  hemicrania ;  such  a 
combination  is  to  me  always  a  suspicious  sign,  and  induces  me 
mimediately  to  direct  my  attention  to  the  possibility  of  chronic 
alcoholic  poisoning.  Otherwise,  the  limb-pains  are  often 
spoken  of  as  resembling  rheumatism,  but  there  is  no  swelling 


PAINS  OF  ALCOHOLISM.  217 

of  joints,  and  usually  no  decided  tenderness  of  the  painful 
parts.  The  patient  lias  usually  a  particular  worn  and  haggard 
appeai'ence,  coraplauis  of  intense  fatigue  after  the  most 
moderate  muscular  exertion,  and  is  usually  utterly  indisposed 
to  physical  exercise  even  though  the  mind,  as  already 
said,  may  display  a  feverish  activity. 

So  far  as  I  have  seen,  the  subjects  of  this  alFection  are  by  far 
the  most  frequently  women;  and  I  am  inclined  to  attribute 
this  pi-edisposition  of  the  sex  not  to  inherent  peculiar- 
ities of  female  organization,  but  to  the  fact  that  a  much 
larger  proportion  of  intemperate  woiuen  than  of  intemperate 
men  indulge  in  secret  excess.  They  never  get  drunk,  probably, 
but  they  fly  to  the  relief  of  alcohol  upon  every  trivial  occasion 
of  bodily  or  mental  distress ;  and  this  habit  may  have  been 
going  on  for  years  before  it  comes  to  be  suspected  by  their 
friends  or  their  medical  attendant.  Meanlime,  they  have  been 
more  or  less  looked  upon,  and  have  looked  upon  themselves  as, 
"debilitated"  and  "neuralgic"  subjects,  and  have  come, 
either  with  or  without  mistaken  medical  advice,  to  consider 
-free  stimulation  as  the  proper  treatment  for  the  very  ailments 
which  have  been  produced  by  their  own  unfortunate  habits.  I 
cannot  avoid  the  expression  of  the  misgiving,  that  imperfect 
diagnosis,  and  consequent  erronous  prescription,  have  done 
great  harm  in  many  such  cases.  It  has  happened  to  me 
no  less  than  three  times  within  the  last  six  months  to  be  called 
to  lady  patients,  all  suffering  from  alcoholism  induced  by  a 
habit  of  taking  stimulants  for  the  relief  of  so-called  neuralgic 
pain ;  and  in  the  most  distressing  of  these  the  mischief  had  been 
greatly  aggravated  by  a  pei^scription  of  brandy,  based  on  the 
erronous  idea  that  the  pains  were  truly  neuralgic.  I  have 
already  protested  against  this  kind  of  medication,  even  in  cases 
that  are  truly  neuralgic  in  character;  but  it  is  doubly  niis- 
chievous  where  given  for  a  state  of  things  which  actually 
depends  on  alcoholic  excess. 

It  is  undoubtedly  very  difficult,  sometimes,  to  elicit  the  truth, 
even  in  cases  where  we  may  entertain  considerable  suspicion 
that  alcoholic  excesses  are  the  real  cause  of  tlie  pains  which 
the  patient  calls  neuralgic  ;  rjiore  especially  where  the  patient 
is  awaro  that  he  or  she  is  taking  an  amount  of  alcohol  which 
is  seriously  damaging  to  health.  And  it  is  therefore  necessary 
to  look  out  for  every  possible  additional  help  to  our  diagnosis. 
Besides  the  cardinal  features  of  the  disease — the  insomnia,  loss 
of  appetite,  foul  breath,  haggard  countenance,  and  pains 
encircling  the  limbs  near  the  joints  rather  than  running 
longitudinally  down  the  extremities — there  are  certain  moral 
characteristics  of  the  patient  that  often  tells  a  significant  tale. 
The  drinker,  especially  if  a  woman,  is  shifty,  voluble,  and  full 
of  plausible  theories  to  account  for  this  and  the  other  pheno- 
menon.    It  will  be  well  to  try  the  effects  of  a  somewhat  sud- 


218  THE  PAINS  OF  SYPHILIS. 

den  tliougla  not  "uncourteous  remark,  to  the  effect  that  the  diet 
should  be  strictly  unstimulatiiig.  If  this  be  introduced  with 
some  abruptness,  in  the  course  of  a  conversation  not  appar- 
ently leading  to  it,  the  patient's  manner  will  not  unf  requently 
betray  the  truth ;  while,  if  our  suspicions  are  groundless,  we 
shall  also  probably  perceive  that,  in  the  unconscious,  or 
frankly  surprised,  expression  of  the  countenance.  We  may 
sometimes  derive  crowning  proof  of  the  existence  of  alcoholic 
excess  hj  cautious  questions  which  at  least  reveal  the  fact  that 
the  patient  suffers  from  spectral  hallucinations ;  this  is  a  far 
commoner  occurrence  in  chronic  alcoholism  than  is  generally 
supposed;  it  needs  to  be  inquired  for  with  great  tact,  but, 
when  established  beyond  doubt,  and  joined  to  insomnia  and 
the  peculiar  foul  breath,  is  of  itself  sufficient  to  establish  a 
positive  diagnosis  of  alcoholic  poisoning. 

The  results  of  treatment,  in  true  neuralgia  and  in  alcoholic 
pains,  resi^ectively,  establish  an  important  difference  between 
these  affections.  In  the  former  malady,  for  instance,  the  hypo- 
dermic injection  of  n"iorphia  always  produces  strikmg  pallia- 
tive, and  very  often  curative  effects.  In  alcoholic  pains  this 
remedy  either  affords  only  trifling  relief,  or  more  commonly 
aggravates  the  malady  by  increasing  the  general  nervous 
excitement ;  and  the  only  true  treatment  is  at  once  to  suspend 
all  vise  of  stimulents,  to  administer  quinine,  and  to  insist  upon 
a  copious  nutrition.  If  any  hypnotic  must  be  employed,  let  it 
be  chloral,  or  bromide  of  potassium  with  cannabis  Indica.  It 
will  be  well  also  to  put  the  patient  upon  a  somewhat  length- 
ened course  of  cod-liver  oil.  Tliei'e  is  one  special  symptoin 
from  which  the  chronic  alcoholist  often  suffers  acutely,  namely 
a  hypersensitiveness  to  cold ;  for  this  I  found  the  use  of 
Turkish  bath  two  or  three  times  a  week,  for  three  or  four 
weeks,  very  useful  in  one  case  that  was  under  my  care.  It 
will  be  important  to  insist  that  the  patient  shall  take  the  bath 
only  after  that  shorter  method  which  I  have  described  in  speak- 
ing of  the  prophylaxis  of  true  neuralgia. 


CHAPTER  VII. 

THE   PAINS   OF  SYPHILIS, 

Syphilis,  as  has  already  been  shown  in  Part  I.  of  this  work, 
may  excite  true  neuralgia  in  subjects  already  predisposed  to 
the  latter.  The  case  of  Matilda  W. ,  previously  given,  is  an 
example.  The  pains,  however,  which  are  now  to  be  described, 
are  those  which  occur  in  the  ordinary  course  of  a  constitutional 
syphilitic  infection,  and  have  nothing  to  do  with  neuralgia 
proper,  from  which  they  should  be  carefully  distinguished. 


THE  PAINS  OF  SYPHILIS.  219 

There  are  two  varieties  of  syphilitic  pains  proper,  which  are 
quite  distinct.  The  first  kind  is  represented  by  the  so-called 
dolores  osteocopi,  which  occur  in  the  early  stages  of  the  con- 
stitutional affection,  coincidently  with,  or  just  before,  the  sec- 
ondary skin-eruptions.  The  second  kind  are  those  Avhich  occur 
in  the  tertiary  stage,  and  are  the  immediate  precursors  of  the 
formation  of  peiiosteal  nodes. 

It  is  the  first  of  these  varieties  of  syphilitic  pains  which  is 
least  commonly  confounded  witli  neuralgia.  The  pain  is 
referred  to  the  superficial  bones,  of  which  those  most  frequently 
attacked  are  the  forehead,  sternum,  clavicle,  ulna,  and  tibia, 
pretty  much  those  selected  for  the  growth  of  nodes  at  a  later 
stage  of  the  disease.  Besides  the  bones,  the  shoulders,  elbows, 
and  nape  of  the  neck  are  attacked  sometimes  simultaneously, 
sometimes  successively.  The  pains  are  readily  controlled  by 
proper  treatment;  if  untreated,  their  course  is  very  uncertain. 
When  they  manifest  themselves  at  the  outset  of  the  disease, 
they  usually  cease  when  the  cutaneous  eruption  is  fairly  out. 
Commonly,  there  is  no  swelling  or  heat  at  the  painful  places ; 
but,  when  the  pains  are  very  severe,  nodes  now  and  then  form 
at  this  early  period.* 

These  early  syphilitic  pams,  in  their  violent  aching  charac- 
ter, and  their  intermittence,  occasionally  resemble  true  neural- 
gia very  closely ;  but  they  are  usually  distinguished  from  it  by 
their  symmetrical  disposition  and  by  their  attacking  several 
bones  at  once.  Moreover,  they  nearly  always  show  the  pecu- 
liarity of  being  distinctly  aggravated  by  the  warmth  and 
repose  of  bed  even  if  tliey  be  not  altogether  absent  (as  is  not 
unfrequently  the  case)  when  the  patient  is  up  and  moving 
about.  A  typical  ease  of  this  kind  is  not  so  likely  to  be  con- 
founded with  neuralgia  as  with  rheumatism ;  but  we  occasion- 
ally meet  with  cases  in  which  the  pains  are  localized  in  a  man- 
ner much  more  resembling  the  former.  Thus  I  have  met  with 
several  instances  in  which  a  patient,  entirely  unconscious  (or 
professing  to  be  unconscious)  of  having  been  syphilized,  com- 
plained of  violent  pain  in  one  tibia,  recurring  every  night  at  a 
certain  hour,  and  at  first  un  distinguishable  from  that  variety  of 
sciatica  in  which  the  pain  is  principally  felt  in  this  situation, 
especially  as  it  was  relieved  by  firm  pressure,  just  as  neuralgia 
is  in  the  eai'ly  stages.  And  in  one  remarkable  case,  which  came 
under  my  care  at  Westminster  Hospital,  the  resemblance  to 
clavus  was  most  misleading: 

H.  A. ,  aged  nineteen,  woi^ker  in  a  laundry,  presented  herself 
on  account  of  a  violent  pain  in  the  right  parietal  region,  recur- 
ring three  times  daily  with  great  regularity.  The  first  two 
attacks  occurred  in  the  day-time,  the  third,  which  was  always 
the  severest,  woke  her  out  of  sleep  about  midnight ;  the  pain 

♦Berkeley  Hill,  "  Syphilis  and  Local  Contagious  Disorders,"  p    153. 


230  THE  PAINS   OF  SYPHILIS, 

of  tliis  last  was  so  agonizing  that  on  more  than  one  occasion 
she  had  become  delirious .  Tiie  girl  (whose  respectable  a'ppeav- 
ance  was  against  the  notion  of  syphilis)  was  veryansemic; 
not,  however,  with  the  tint  either  of  anaemic  from  hcemor- 
rhage,  or  witli  that  of  chlorosis,  exactly.  It  was  I'ather  a  dirty 
sallowness  of  skin ;  but  the  gums  and  the  conjunctivas  were 
exceedii:igly  bloodless,  and  she  complained  of  almost  constant 
noises  in  the  head.  Menses  scanty  but  regular.  There  v^^as  a 
soft  anaemic  bruit  with  the  first  sound  at  the  base  of  the  heart. 
Having  failed  to  make  any  impression  on  the  pains  with  iron 
and  witli  muriate  of  ammonia  m  large  doses,  I  was  led  to 
observe  the  fact  that  there  was  no  diffuse  soreness  of  tlie  scalp, 
such  as  very  commonly  occurs  in  clavus,  in  the  intervals  of 
the  pains,  and  the  mere  fact  that  there  was  this  unusual  cir- 
cumstance in  the  case  led  me  to  reconsider  the  diagnosis 
thoroughly.  In  order  to  be  sure  of  not  omitting  a  point,  I 
inquired,  though  without  any  expectation  of  an  affirmative 
answer,  as  to  the  possibility  of  syphilitic  disease ;  the  girl  at 
once  confessed  to  having  had  sores,  and  examination  detected 
a  papular  rash  about  the  shoulders  and  back  and  on  both 
thighs.  Small  doses  of  mercury  greatly  relieved  the  pain 
within  a  week,  and  cured  it  in  less  than  three  weeks ;  and  it 
was  very  remarkable  that  the  anaemia,  which  had  obstinately 
refused  to  yield  to  iron,  improved  at  once  as  the  mercury 
began  to  relieve  the  pains.  The  eruption  disappeared  simulta- 
neously. 

It  is  the  later  pains  of  syphilis,  however,  tliat  are  most  fre- 
quently confounded  with  neuralgia,  and  occasionally  Avith  very 
disastrous  results.  These  pains,  which  are  tlie  precursors  of 
the  formation  of  true  nodes,  frequent  the  •  same  localities  as 
those  affected  by  the  earlier  pains ;  they  may  exist  in  consider- 
able severity  for  days,  or  even  for  many  weeks,  before  any 
node-formation  can  be  detected.  The  situation  in  which,  of 
all  others,  they  are  likely  to  be  mistaken  for  neuralgia  is  the 
scalp  or  face,  especially  when  a  single  spot  is  affected  on  one 
side,  and  in  the  situation  of  one  of  the  usual  foci  of  trigeminal 
or  occipital  neuralgia.  I  have  personally  known  the  mistake 
to  be  made  with  syphilitic  affections  causing  pain,  respectively, 
in  the  superciliary  region,  in  the  malar  bone,  the  jaw  near  the 
mental  foramen,  and  the  parietal  eminence. 

The  possibihty  of  mistaking  tertiary  syphilitic  pain  for  neu- 
ralgia is  fraught  with  such  grave  dangers,  that  we  ought  to  be 
constantly  and  most  vigilantly  on  the  watch  against  it.  But 
most  especially  is  this  the  case  when  the  pain  is  situated  in 
some  part  of  the  cranium,  as  the  parietal  or  temporal  eminen- 
ces, the  mastiod  process,  or  the  prominences  of  the  occipital 
bone.  For  it  must  be  remembered  that  the  same  process, 
which  forms  syphilitic  nodes  upon  the  external  surface  of 
bones,  or  within  bony  canals,  can  produce  them  on  the  lining' 


THE  PAINS  OF  SYPHILIS.  221 

membrane    of   the    skull,    with   most  serious  consequences, 
should  the  symptoms  be  neglected  or  misunderstood. 

The  pains  produced  by  nodes  upon  the  internal  surface  of 
the  ci^anium  are  usually  of  a  very  intense  character,  and  are 
mostly  continuous,  though  aggravated  from  time  to  time, 
especially  at  night.  Where  syphilitic  inflammation  is  diffused 
over  a  considerable  portion  of  the  meninges,  it  is  certain  very 
quickly  to  produce  symptoms  which  can  hardly  fail  to  apprise 
us  of  the  gravity  of  the  affection ;  there  will  be  decided  and 
rapidly  increasing  impairment  of  memory,  and  general  cloudi- 
ness of  intellect,  tending  toward  complete  imbecility,  the  spe- 
cial senses  will  be  greatly  interfered  with  or  lost,  and  muscu- 
cular  paralysis  will  be  developed.  But  in  the  case  of  a  more 
limited  syphilitic  affection  of  the  dura  mater,  pain,  of  the  kind 
already  described,  may  be  for  some  days  the  only  very  notice- 
able symptom.     The  following  is  an  mstance : 

J.  E.,  aged  forty-seven,  a  street  and  tavern  singer,  applied 
to  me  (November  14,  ISGl),  on  account  of  severe  pain  in  the 
right  temporal  region,  which  had  on  the  whole  the  character 
of  neuralgia,  though  rather  more  continuous  than  such  pain 
usually  is.  He  said  that  it  commenced  on  the  10th,  without 
any  particrdar  provocation  that  he  knew  of,  and  that  it  had 
hardly  left  him  at  all  from  that  moment.  .It  kept  him  awake 
at  night,  and  that  circumstance  seemed  to  account  sufficiently 
for  a  very  worn  and  depressed  look  which  he  presented ;  he 
was  otherwise  a  robust-looking  man,  and  at  first  denied  having 
suffered  from  any  previous  illness.  The  pain  always  came  to 
a  climax  about  one  o'clock,  A.  M.,  waking  him  out  of  his  first 
sleep  in  agony,  and  allowing  him  little  rest  for  the  remainder 
of  the  night ;  toward  morning  he  would  drop  to  sleep  for  an 
hour  or  so.  There  was  no  particular  tender  point,  corresponding 
to  any  recognized  neuralgic  focus,  yet  the  pain  was  limited  most 
strictly  to  a  spot  that  might  be  covered  with  two  finger-points. 
There  was  no  lachrymation  nor  conjunctival  congestion,  and 
nothing  to  remark  in  any  way  about  either  eye.  The  patient 
was  ordered  quinine  in  large  doses,  in  the  belief  that  the  pain 
was  neuralgic.  On  the  following  day  he  reported  himself  a 
trifle  better,  though  still  suffering  greatly ;  and  on  the  _af tei-- 
noon  of  that  day  there  was  an  almost  complete  intermission  of 
the  pain  for  several  hours ;  but  it  returned  severely  at  the 
usual  nocturnal  period.  On  the  16th,  at  10  A.  M.,  he  carae  to 
my  house  looking  exceedingly  ill,  but  the  only  additional 
symptom  that  I  could  detect  was  a  small  di'OJp  of  the  right 
eyelid.  He  was  subscutaneously  injected  with  one-fourth  of  a 
grain  of  morphia  and  sent  home,  where  he  immediately  fell 
into  a  heavy  sleep  that  lasted  till  bedtime.  He  awoke,  un- 
dressed himself  without  feeling  much  pain,  and  got  to  bed ; 
after  an  hour  or  so  of  dozing  he  was  awakened  by  the  pain, 
which  was  exceedingly  severe.     On  the  17th  he  called  on  m.e 


222  THE  PAINS  OF  SYPHILIS. 

in  tlie  morning,  and  I  at  once  perceived  that  the  ptosis  of  the 
right  eyelid  was  much  greater,  and  the  right  pupil  was  much 
dilated  and  insensitive,  and  the  external  rectus  was  i)aralyzed ; 
the  man  also  woi^e  a  look  of  stupidity,  and  answei'ed  questions 
with  an  apparent  mental  effort.  I  now  cross-questioned  him 
more  closely ;  and  also  explored  the  tibiae  and  other  superficial 
bones :  on  the  sternum  a  distinct  though  not  ver^^  advanced 
node  was  found.  Ui^on  this  he  was  induced  to  coiifess  that  he 
had  suffered  from  chancre  three  years  and  a  half  previously, 
and  subsequently  had  "blotches"  on  the  skin,  which  had 
quickly  disappeared  under  treatment,  of  which  all  that  could 
be  learned  was,  that  it  was  fluid  medicine  and  did  not  make 
his  mouth  sore.  He  was  immediately  ordered  to  take  two 
grains  of  calomel  in  pill,  with  a  little  opium,  every  four  hours. 
He  had  only  taken  one  dose  when  I  was  sent  for  to  him,  and 
found  him  in  an  epileptiform  convlusion,  in  which  the  left 
side  of  the  body  was  almost  exclusively  affected ;  the  convul- 
sions recurred  several  times  durmg  the  next  twenty-four  houi^s, 
and  in  the  intervals  he  remained  almost  completely  uncon- 
scious. The  mercurial  treatment  was  pushed,  in  the  form  of 
calomel- powders  placed  on  the  tongue.  On  the  evening  of  the 
18th  he  began  to  recover  consciousness,  and  then  had  a  little 
natural  sleep;  the  next  morning,  at  10  A.  M.,  he  was  found  to 
be  fully  conscious,  had  had  no  return  of  convulsions,  but  the 
left  arm  and  leg,  esj)ecially  the  latter,  were  almost  entirely 
powerless ;  the  parietal  headache  had  vanished ;  the  gums  were 
slightly  tender ;  the  thh'd  and  sixth  nerves  of  right  side  were 
completely  paralyzed.  Mercurial  treatment  was  very  gently 
continued,  so  as  to  keep  the  patient  on  the  borders  of  pytalism 
for  the  next  three  or  four  days;  and  he  was  then  put  on  full 
doses  of  iodide  of  potassium.  The  pain  never  recurred ;  the 
left  extremities  recovered  power  i^apidly ;  but  it  was  six  weeks 
before  the  ocular  paralyses  were  completely  well. 

Late  in  the  autumn  of  1865  I  was  sent  for  hastily  one  even- 
ing to  see  this  same  man,  and  found  him  totally  unconscious 
and  apparently  again  hemiplegic,  but  now  on  the  right  side. 
He  was  miserably  wasted,  and  covered  with  a  rupious  eruption ; 
I  was  informed  that  he  had  been  leading  a  most  debauched 
and  drunken  life  for  some  time  past,  and  that,  after  looking 
extremely  ill,  and  appa^rently  half  imbecile  for  a  week  or  two 
past,  he  had  suddeiily  fallen  down  unconscious  in  the  street  a 
few  hours  before  I  saw  him.  He  remained  deeply  comatose, 
and  died  the  next  morning;  no  j^ost  mortem  could  be 
obtained. 

The  true  neuralgias  in  which  syi^hilis  only  plays  the  part  of 
secondary  factor,  and  which  have  been  referred  to  in  Part  I. 
of  this  work,  may  de]3end  for  tbeir  exciting  cause  on  local 
syphilitic  processes,  affecting  either  the  peripheral  distribution, 
the  main  trunk  or  the  central  origin  of  a  sensory  nerve ;  but  I 


THE  PAINS  OF  SYPHILIS.  223 

have  pointed  out  the  fact  that,  whatever  the  reason  may  be, 
syphilis  does  but  rarely  attack  the  central  portions  of  individ- 
ual sensory  nerves,  in  comparison  with  the  frequency  with 
which  it  attacks  individual  motor  (cranial)  nerves.  But  with- 
out any  neuralgic  predisposition  at  all-,  and  without  any  limi- 
tation of  the  syphilitic  process  to  a  particular  sensory  nerve, 
the  latter  may  become  neuralgic  in  consequence  of  being  in- 
volved in  extensive  intra-cranial  or  natra-spinal  syphilitic  mis- 
chief. The  trigeminus  is  liable  to  suiter  in  this  way  from 
spreading  syphilitic  processes  about  the  base  of  the  brain ;  and 
my  own  impression  is,  that  the  cause  of  the  neuralgic  pain  in 
some  such  cases  is  the  extension  of  the  mischief  to  the  verte- 
bral artery  of  the  aif ected  side,  leading  to  intcjrfering  with  the 
nutrition  of  the  trigeminal  nucleus  in  the  medulla.  A  very 
interesting  case  is  reported  by  Dr.  Hughlings  Jackson  (who  has 
done  so  much  to  acquaint  us  with  syphilitic  affections  of  cere- 
bral arteries)  in  vol.  iv.  of  the  "London  Hospital  Reports,"  pp. 
318-331.  The  patient  was  a  woman,  aged  twenty-seven,  and 
the  initial  symptoms  of  the  malady  which  destroyed  her  life 
were  violent  trigeminal  neuralgic  pains  on  the  right  side :  sub- 
sequently she  had  complete  paralysis  of  the  fifth,  and  of  the 
sixth,  seventh,  and  eighth  nerves  of  the  right  side.  After 
death  the  right  vertebral  artery  was  found  engaged  in  the 
mass  of  syphilitic  deposit;  it  must  be  added,  however,  that  the 
(superficial)  origin  of  the  fifth  nerve  was  itself  softened,  oppo- 
site the  pons.  Another  mode  in  which  syphilitic  disease  very 
probably  causes  neuralgia  of  the  fifth,  in  a  certain  number  of 
cases,  is  by  injuring  the  Gasserian  ganglion,  upon  the  integ- 
rity of  which  (according  to  Waller's  general  law  concerning 
the  ganglia  of  posterior  nerve-roots)  the  nutrition  of  the  sen- 
sory root  of  the  trigeminus  materially  depends.  I  have  seen 
an  example  (as  I  cannot  but  suppose)  of  this  sequence  of  mor- 
bid events ;  the  evidence  appears  sufficiently  complete,  although 
I  was  unable  to  obtain  a  2^081  mortem  examination : 

W.  M.,  a  house  painter,  of  extremely  dissipated  habits,  but 
who  had  never  suffered  either  from  distinct  symptoms  of  alco- 
holism, nor  from  any  affection  traceable  to  lead-poisoning.  In 
M?^rch,  1867,  he  applied  to  me  on  account  of  neuralgic  pain, 
affecting  chiefly  the  right  eyeball,  but  also  darting  along  the 
course  of  the  frontal  nerve  of  thatside  ,*  after  a  short  time  it 
extended  also  into  the  infra-orbital  nerves.  He  bore  several 
scars  of  tertiary  ulcers  about  the  nose  and  forehead,  and  made 
no  secret  of  having  suffered  from  cnancre  six  or  seven  years 
before,  and  from  subsequent  secondary  and  tertiary  symptoms. 
I  was  consequently  not  at  all  surprised  at  ins  developing  severe 
iritis  (right)  after  he  had  been  a  fortnight  under  my  care, 
although  I  had  from  the  first  given  large  doses  of  iodide  of 
potassium ;  but  I  was  not  prepared  for  the  extensive  processes 
of  destruction  which  followed,  notwithstanding  that  1  imme- 


224:  THE  PAINS  OF  SYPHILIS. 

diately  commenced  mercurial  treatment,  and  applied  atropine. 
I  remarked  that  while  the  inflammation  of  the  iris  proceeded 
with  great  violence,  the  cornea  was  also  much  more  severely 
affected  than  is  usually  the  case  in  syphilitic  iritis  ;  in  fact,  the 
changes  closely  resembled  those  which  have  been  noted  after 
section  of  the  fifth  at  the  Gasserian  ganglion,  ajad  at  the  date 
of  the  patient's  death  (seventeen  days  from  the  commencement 
of  the  iritis)  a  corneal  ulcer  was  on  the  point  of  perforating. 
For  the  first  three  or  four  days  after  the  iritis  set  in,  the  neu- 
ralgic pains  went  on  augumenting  in  intensity,  and  extended 
into  all  three  divisions  of  the  fifth ;  there  was  a  copious  dis- 
charge from  the  right  nostril.  Almost  suddenly,  on  the 
fourth  day,  the  pains  abated  and  then  ceased,  and  it  was  now 
evident  that  the  whole  surface  of  the  right  half  of  the  face  was 
completely  anesthetic.  Two  days  later  a  dark-red  patch  ap- 
peared on  the  cheek,  and  in  the  course  of  the  next  two  days 
this  ulcerated,  the  ulcer  presenting  a  somewhat  livid  appear- 
ance, and  exuding  a  sanious  discharge  ;  at  the  same  time, 
superficial  ulcers  appeared  on  the  right  side  of  the  tongue,  and 
coalesced  to  foiin  one  large  sore.  The  sores  both  on  cheek  and 
tongue  assumed  more  and  more  a  gangrenous  appearance,  and 
on  the  sixteenth  day  from  the  commencement  of  iritis  there 
was  considerable  loss  of  substance  ni  both  these  situations.  On 
the  evening  of  this  day  (the  patient  having  become  extremely 
depressed  and  much  emaciated)  general  epileptiform  convul- 
sions set  in,  and  followed  each  other  rapidly;  in  a  few  hours 
coma  supervened,  and  the  patient  sank  the  next  day.  No  post 
mortem  could  be  obtained ;  but  it  seems  extremely  probable, 
from  the  above  history,  that  the  Gasseinan  ganglion  was  early 
involved  in  the  syphilitic  inflammation,  and  that  the  neural- 
gia and  subsequent  anaesthesia,  the  iritis,  and  the  other  trophic 
lesions,  were  due  to  the  injury  inflicted  upon  it. 

The  treatment  of  syphilitic  pains  will,  in  doubtful  cases, 
often  give  us  valuable  asssurance  of  the  correctness  of  our 
diagnosis.  Where  the  disease  is  extensively  diffused,  we  may 
fail  to  do  any  good;  but,  in  cases  where  the  syhilitic  mischief 
is  limited  to  a  small  portion  of  the  meninges,  we  may  often 
arrest  it.  In  all  merely  suspicious  cases,  where  the  pain  is  thus 
limited,  it  will  be  well  to  use  iodide  of  potassium  tentatively — 
forty  to  sixty  grains  daily.  But,  where  the  pains  are  very 
severe  and  continuous,  and  there  is  danger  to  the  integrity  of 
the  eye,  or  threatenings  of  a  paralytic  attack  are  observed,  it  is 
better  not  to  trust  to  anything  short  of  mercury,  used  in  such 
a  manner  as  just  to  stoiD  short  of  absolute  ptyalism.  In  very 
bad  cases,  like  the  last  one  narrated,  we  may  fail  to  produce 
any  good  effect,  but,  where  the  specific  treatment  is  com- 
menced in  good  time,  we  may  not  unfrequently  succeed  in 
arresting  the  symptoms  with  a  rapidity  that  assures  us  of  the 
correctness  of  the  diagnosis  of  syphilis. 


PAINS  OF  SUBACUTE  AND   CHRONIC  RHEUMATISM.  235 

CHAPTER  VIII. 

PAINS  OF  SUBACUTE  AND  CHRONIC    RHEUMATISM. 

So  firmly  is  the  idea  of  an  essential  connection  between 
rheumatism  and  neuralgia  implanted  in  tlie  popular  mind, 
and,  indeed,  in  the  minds  of  a  certain  portion  of  the  medical 
profession,  that  tlie  two  complaints  are  continually  confounded. 
In  the  great  majority  of  instances,  the  mistake  made  is  that  of 
calling  neuralgia  a  "rheumatism."  But  the  opposite  error 
occasionally  occurs,  and  a  patient  is  styled  "neuralgic"  who 
is  really  suffering  from  chronic  rheumatism. 

As  true  neuralgia  is  an  essentially  localized  disease,  there 
can  be  no  excuse  for  mistaking  for  it  the  more  typical  cases  of 
chronic  rheumatism,  in  which  a  number  of  different  joints, 
muscles,  or  tendons,  are  affected,  more  especially  in  the 
advanced  stages,  when  the  cliaracteristic  fixed  contractions  of 
the  limbs  and  extremities  have  occurred.  But  there  are  a  few 
cases  in  which,  either  with  or  without  a  j)revious  history  of 
acute  rheumatism,  one,  or  perhaps  two,  joints  begin  to  suffer 
vague  pains,  which  after  a  little  time  begin,  to  shoot  down  the 
course  of  the  limb,  and  are  aggravated  from  time  to  time  in  a 
manner  which  super'iicially  much  resembles  neuralgia;  and 
when  the  ixialady  has  reached  a  certain  iiitensitj^  the  pains  may 
be  so  much  more  severely  felt  in  the  longitudinal  axis  of  the 
limb  than  in  the  immediate  neighborhood  of  a  joint,  that  the 
patient  forgets  that  in  reality  they  commenced  either  within  a 
joint  (as  the  elbow  or  hi])),  or  in  the  fibrous  structui'es  imme- 
diately outside  it.  Certain  localties  are  mucli  more  frequently 
the  seat  of  this  kind  of  affection  than  other  parts  of  the  body ; 
thus  it  occurs,  perhaps  in  nine-tenths  of  the  cases,  in  the  neigh- 
borhood either  of  the  shoulder  (especially  involving  the  inser- 
tions of  the  deltoid  and  triceps  muscles),  of  the  elbow  (particu- 
larly affecting  the  tendinous  ii^sei-tions  of  the  muscles  on  the 
internal  aspect  of  the  forearm),  or  the  hi]3  (extending  to  the 
aponeuroses  on  the  outer  and  back  part  of  the  thigh) :  in  all 
these  cases  there  is  a  considerable  superficial  resemblance  to 
true  neuralgic  pains.  Nevertheless,  the  diagnosis  need  not 
present  any  serious  difficulties  after  the  earliest  stages:  for 
tliere  soon  arises  a  very  diffuse  and  acute  tenderness  of  the 
parts,  and  usually  an  amount  of  generalized  swelling,  which, 
though  it  may  not  be  readily  detectable  by  the  eye,  is  sensible 
enough  to  the  touch.  Movement  of  the  parts  is  also  very  pain- 
ful ;  but  usually  not  with  the  acute  and  agnozing  pain  which 
occurs  in  myalgia. 

It  is,  however,  upon  signs  which  are  of  a  more  general  char- 
acter that  we  ought  chiefly  to  rely  for  diagnosis.  The  fact 
that  the  patient  has  previously  experienced  a  genuine  attack  of 


22Q         PAINS  OF  SUBACUTE  AJ^D  CHRONIC  RHEUMATISM. 

acute  rheumatism,  though  of  some  value,  is  hy  no  means  to  be 
taken  as  a  conclusive  argument  that  the  present  attack  is  of  a 
rheumatic  nature.  The  really  important  matter  is,  that 
whether  the  patient  has  or  has  not  suffered  acute  rheuma- 
tism before  the  occurrence  of  the  subacute  or  chronic  form, 
tlie  latter  will  always  be  attended  bv  more  or  less  of  the  spe- 
cific constitutional  disturbance  of  rheumatism.  I  would  care- 
fully abstain  from  the  assumption  that  rheumatism  is  origin- 
ally dependent  on  a  blood-poisoning,  a  theory  which  I  believe 
to  be  most  doubtful  and  very  probably  false ;  but  there  is, 
nevertheless,  a  truly  specific  character  about  the  general  phe- 
nomena in  acute  rheumatism,  and  I  maintain  that  similar 
though  less-marked  phenomena  are  always  to  be  seen  even  in 
the  mildest  and  least  acute  forms  of  rheumatism.  Thus  there 
will  be,  invariably,  more  or  less  of  the  peculiar  sallow  anae- 
mia, together  with  red  flushing  of  the  cheeks  when  the  j)ain  is 
at  the  worst;  and  there  will  be  a  certain  amount  of  the  oily 
perspiration  which  makes  the  faces  of  rheumatic  patients  look 
shiny  and  greasy.  No  doubt  these  characteristics  will  some- 
times be  very  slightly  developed,  but  I  believe  that  attentive 
observation  will  always  discover  them  in  any  case  which  is 
genuinely  rheumatic.  One  case,  in  particular,  which  has  been 
under  my  care,  very  strongly  impresses  me  with  the  value  of 
these  diagnostic  signs,  where  otherwise  the  S3^mptoms  are 
obscure : 

L.  P.,  aged  thirty-one,  single,  a  printer  by  trade,  applied  to 
me,  January,  1863,  suffering  from  what  I  at  fl.rst  decidedly 
thouglit  was  cervico-brachial  neuralgia,  the  pain  having  fol- 
lowed exposure  to  cold  and  wet,  situated  in  the  lower  part  of 
the  neck,  the  shoulder,  elbow  and  inner  side  of  the  right  arm, 
and  existing  nowhere  else.  The  character  of  the  pain  was 
described  as  at  least  remittent,  if  not  distinctly  intermittent. 
The  pulse  was  not  more  than  78 ;  the  tongue  was  thickly  coated 
with  white  fur,  but  the  man  did  not  complain  of  thirst,  and 
there  were  no  evident  signs  of  fever.  As  the  pains  had  only 
existed  for  about  a  fortnight,  it  appeared  an  excellent  case  for 
cure  by  the  hyj)odermic  injection  of  morphia;  and,  accord- 
ingly this  was  used  in  quarter-grain  doses  twice  a  day.  After 
about  ten  days  an  attempt  was  made  to  do  without  the  mor- 
phia, but  the  pains  I'eturned,  worse  than  before,  and  meantime 
the  tongue  had  remained  uniformly  coated,  and  was  now  very 
yellow ;  the  appetite  was  bad,  and  there  was  some  increase  in 
frequency  of  pulse.  It  now  struck  me,  for  the  first  time,  that 
the  man  presented,  in  a  slight  degree,  the  sallow  and  red  tint 
and  oily  features  of  a  rheumatic  patient ;  it  was  now  _  found 
that  sweat  and  urine  were  distinctly  acid.  Acting  on  this  idea, 
I  administered  five  grains  of  iodide  of  potassium,  and  thirty 
grains  of  bicai-bonate  of  potassium,  four  times  every  twenty- 
four  hours,  after  giving  a  moderate  saline  aperient.     The  result 


PAINS  OF  LATENT  GOUT.  227 

was  manifest  improvement  within  twenty-four  hours,  and 
ah-nost  complete  relief  of  the  pain  within  three  or  four  days 
(the  urine  never  becoming  distinctly  alkaline,  however.)  As 
the  attack  subsided,  the  oily  appearance  of  the  skin  disap- 
peared, and  the  rheumatic  tint  was  replaced  by  mere  ordinary 
pallor,  which  the  patient  lost  after  taking  a  short  course  of 
steel. 

At  the  time  this  case  occurred  to  me,  I  was  not  aware  of  the 
importance,  in  doubtful  instances,  of  looking  to  the  temrei'a- 
ture ;  but  subsequent  experience  has  convinced  me  that  in  eveiy 
truly  rheumatic  case,  however  limited  in  extent,  there  is  a  real, 
though  it  may  be  a  small,  rise  of  temperature.  The  thermom- 
eter will  be  found  to  mark  from  99i°  to  100°  Fahr.,  and  this, 
joined  with  the  appearances  above  mentioned,  and  a  strong 
acidity  of  urine,  will  be  sufficient  to  distinguish  the  complaint 
as  rheumatic;  and  the  striking  effect  of  such  remedies  as  iodide 
with  bicarbonate  of  potash,  followed  up  with  sesquichloride  of 
iron,  in  full  doses,  helps  still  further  to  distinguish  the  cases 
from  true  neuralgias.  Since  the  introduction  of  the  full  doses 
of  the  iron-tincture  in  the  treatment  of  acute  rheumatism,  I 
have  had  the  opportunity  of  treating  two  of  these  cases  of 
subacute  rheumatism  in  the  same  manner,  viz .,  with  the  iron 
from  the  first,  and  the  results  have  been  most  satisfactory  in 
every  way.  These  cases  were  independent  of  a  much  larger 
number,  treated  in  the  same  way,  in  which  the  symptoms  of 
rheumatism  were  more  generalized  and  more  severe. 


CHAPTEE  IX. 

PAINS  OF  LATENT  GOUT, 

Pains  which  are  connected  with  a  chronic  and  more  or  less 
latent  form  of  gout  not  unfrequently  receive  the  designation 
"neuralgic,"  and  are  treated  upon  that  erroneous  theory  of 
their  pathology.  I  have  already  endeavored  to  show  that  there 
is  by  no  means  that  intimate  causal  relation  between  gout  and 
neuralgia  which  is  very  commonly  assumed  to  exist :  true  neu- 
ralgia is,  I  believe,  only  caused  in  an  indirect  and  secondary 
manner  by  the  gouty  condition  setting  up  changes  of  the  blood- 
vessels, which  precipitate  the  occurrence  of  the  neuralgic 
malady,  to  which  the  patient  was  otherwise  predisposed  from 
birth.  But  the  common  idea,  both  without  and  within  the 
profession,  seems  to  be  that  neuralgia  is  only  one  expression, 
and  that  a  quite  common  one,  of  the  gouty  habit.  Neverthe- 
less, with  strange  inconsistence,  the  kind  of  truly  gouty  pains 


2:28  PAINS  OF   LATEISTT  GOUT. 

of  wliich  I  am  now  speaking  are  constantly  treated  upon  a 
special  plan,  upon  the  supposition  that  tliey  are  neuralgic. 

There  are  six  situations  in  Avhich  gouty  pains  are  apt  to  be 
developed  in  a  way  to  lead  to  the  false  diagnosis  of  neuralgia: 
(1)  In  the  eye ;  (2)  more  indefinitely  within  the  cranium ;  (3) 
in  tlie  stomach,  simulating  gastralgia;  (4)  in  the  chest,  simu- 
lating angina  pectoris;  (5j  in  the  dorsum  of  the  foot,  simu- 
lating neuralgia  of  the  anterior  tibial  nerve ;  (6)  in  a  somewhat 
diffuse  manner  about  the  hip  and  back  of  thigh,  simulating 
sciatica. 

It  is  not  really  a  common  thuig  to  find  such  cases  very  diffi- 
cult of  diagnosis,  provided  that  the  possibility  of  their  occur- 
rence has  been  carefully  noted;  for  the  gouty  habit  has  a 
number  of  slight  manifestations  which  are  usually  enough  to 
discover  it  even  when  its  more  decided  symptoms  are  entirely 
wanting. 

Tlius,  in  the  first  place,  it  will  be  almost  invariably  found, 
on  inquiry,  that  the  patient  has  always  been  mtolerant  of 
beer  and  of  sweet  wines.  Also,  he  has  been  liable  (either  after 
a  single  large  excess  in  eatmg  or  a  prolonged  course  of  a  diet 
too  higiily  aniraalized  in  proportion  to  the  amount  of  exercise 
taken)  to  attacks  of  general  malaise,  with  or  without  uneasi- 
ness, just  short  of  decided  pain,  about  the  metacarpo-phalan- 
geal  joint  of  the  great-toe,  and  ending  after  a  few  hours  or 
days  with  a  free  discharge  of  uric  acid.  Less  frequently,  but 
still  very  often,  it  will  be  found  that  he  has  some  deposit  of 
lithate  of  soda  (chalk-stone)  in  some  situation  where  its  pres- 
ence does  not  necessarily  arrest  attention;  Dr.  G-arrod  has 
shown  how  often  these  little  tophi  are  found  in  the  cartilage  of 
the  ear.  Careful  examination  v\'ill  sometimes  detect  their 
presence  in  the  sclerotic  of  the  eye.  But  in  doubtful  cases  it 
would  be  always  well  to  make  a  cautious  trial  of  colchicum, 
■which,  if  the  case  be  gouty,  will  nearly  always  produce  an 
amount  of  relief  suificient  to  confirm  the  the  diagnosis  of  gout. 
At  least,  this  rule  holds  goods  for  the  external  forms;  but  in 
the  case  of  the  supposed  gouty  pseudo-angina  it  is  far  best  to 
trust  to  opium,  as  colchicum  may  j)rove  too  depressuig  to  a 
heart  which  may  quite  possibly  be  already  the  subject  of 
organic  disea,se.  My  own  impression  is,  that  it  was  these  cases 
of  gouty  heart-pain,  which  are  not  true  angina  at  all,  that  pro- 
cured for  opium  its  high  reputation  for  relieving  the  latter  dis- 
ease, a  re]3utation  which  is  by  no  means  confirmed  by  mj-  own 
experience,  since  I  have  found  that  drug  enormously  inferior 
to  stimulants  like  ether  in  its  power  to  relieve  genuine  angina. 

Lastly,  if  there  be  no  other  possibility  of  making-  ourselves 
c::rtain  whether  there  is  or  is  not  a  gouty  taint  at  the  bottom 
of  the  quasi-neuralgic  pains,  we  may  adopt  Dr .  Garrod's  test  of 
subjecting  the  serum  of  the  blood  to  a  search  for  uric  acid 
(thread-test). 


COLIC,  AND  OTHER  PAINS  OF  PERIPHERAL  IRRITATION .     239 

CHAPTER    X. 

COLIC,    AND  OTHER  PAINS  OF  PERIPHERAL  IRRITATION. 

Colic,  or  painful  half  spasm,  half  paralysis  of  the  large 
intestines,  is  the  best  example  of  a  kind  of  spasmodic  pains  to 
which  some  authors  accord  the  name  of  neuralgia,  as  it  seemis 
to  me  without  good  reason.  They  appear  to  be  quite  inde- 
pendent of  the  operation  of  the  neurotic  temperament,  and  to 
be  caused  entirely  by  the  operation  of  some  local  irritant,  or 
narcotic  irritant,  upon  the  muscular  fibres  of  the  viscus.  In 
the  case  of  .colic  this  influence  is  most  frequently  and  most 
powerfully  exerted  by  lead,  which  undoubtedly  becomes 
locally  deposited  in  chronic  poisoning  with  that  metal;  at 
other  times  it  is  produced  by  the  irritation  of  indigestible  food 
passing  along  the  alimentary  canal. 

That  there  may  be  such  a  thing  as  enteralgia,  of  really  neu- 
ralgic character,  I  do  not  deny;  on  the  contrary,  so  far  as 
regards  the  rectum,  I  have  myself  seen  such  a  case.  But  true 
neuralgia  of  the  large  bowel  is  exceedingly  uncommon ;  what 
goes  by  the  name  is  usually  either  colic  from  local  irritation 
of  the  viscus ;  or  a  mere  hysterical  hypersesthesia  of  the  lining 
membrane,  which  is  one  of  the  occasional  phenomena  of  spinal 
irritation ;  or  else  it  is  a  case  of  neuralgia  of  the  abdominal 
wall,  such  as  is  included  in  the  description  of  "  lumbo-abdom- 
mal  neuralgia,"  in  Part  I.  of  this  work. 

There  is  no  occasion  to  describe  minutely  the  symptoms  of 
so  familiar  a  disease  as  lead-colic,  or  as  colic  from  irritation  by 
indigestible  food,  when  they  occur  in  their  typical  forms.  In 
the  former  case  the  marked  constipation  which  ushers  in  the 
attack  of  pain,  and  the  peculiar  greenish-yellow  sallowness 
nearly  always  seen  in  the  countenance,  ought  to  be  suiHcient 
to  direct  examination  to  the  gums  (for  the  blue  line)  and 
inquiry  as  to  any  possible  impregnation  of  the  system  with 
lead,  owing  either  to  the  nature  of  the  patients  occupation,  or 
to  some  accidental  entry  of  the  poison  into  the  drinking-water, 
or  its  inhalation  from  the  walls  of  newly-painted  rooms,  etc. 
In  the  latter  case,  the  fact  that  the-  attack  of  coiic  was  shortly 
preceded  by  a  meal,  either  of  obviously  indigestible  food,  or 
too  copious  in  quantity  and  heterogeneous  in  kind,  or  too 
hastily  eaten  without  sufficient  mastication,  supplies  a  clew. 

But  there  are  a  few  cases  representing  minor  degrees  of 
either  of  these  kinds  of  colic,  that  are  much  less  easy  to  diag- 
nose distinctly. 

Lead-poison  sometimes  enters  the  system  continuously,  for  a 
long  period,  but  in  proportions  too  minute  to  produce  the 
effects  which  we  identify  as'  an  attack  of  lead-colic.  I  believe 
that  for  the  production  of  the  latter  complaint  it  is  necessary 


230     COLIC,  AND  OTHER  PAINS  OF  PERIPHERAL  IRRITATION. 

that  the  poisoning  shall  be  sufficiently  intense  completely  to 
paralyze  a  considerable  piece  of  bowel,  thus  altogether  hin- 
dermo-  ijeristalsis,  or,  rather,  makiny  the  peristaltic  acts  of  the 
non-jjaralyzed  portions  above  worse  than  fruitless.  But  there 
is  a  minor  degree  in  which  it  may  happen  that  the  local  affec- 
tion (owing,  I  believe,  to  a  less  extensive  deposit  of  lead  in  the 
bowel)  does  not  reach  the  decidedly  paralytic  stage ;  the  state 
then  is  one  of  irregular  and  painful  cpasm  of  individual  fibres 
(quite  possibly  intei-mingled  with  paralysis  of  a  few  others), 
and  the  practical  result  is  irreg'ularity  of  evacuation — now 
diarrhoea,  and  again  constipation — and  the  frequent  recurrence 
of  twinges  of  pain  that  are  easily  mistaken  for  abdominal 
neuralgia.  Such  symptoms  as  these  are  neai'ly  always  found 
to  have  occurred,  if  proper  inquiry  be  made,  in  those  exam- 
ples of  chronic  lead-poisoning  in  v/hich  the  toxic  process  goes 
on  to  the  development  of  epilepsy,  or  marked  symmetrical 
paralysis  of  the  wrist-extensoi's,  without  the  patient  having 
ever  suffered  an  attack  of  ordinary  colic.  In  these  slow  and 
insidious  cases  the  constitutional  affection  may  not  have 
reached  the  height  at  which  the  complexion  and  general  aspect 
of  the  patient  suggests  metallic  poisonmg :  and  the  case  may 
present  very  neuralgia-like  features.  The  absence  of  the 
points  douloureux  is  not,  as  we  have  seen,  conclusive  against 
neuralgia  in  its  early  stages.  It  is  therefore  an  excellent  rule, 
in  all  cases  of  chronic  recurrent  spasmodic  pain  in  the  abdo- 
men, especiall}^  in  men,  to  investigate  the  possibilities  of  lead- 
poisoning;  and,  if  the  slightest  suspicious  appearance  of  the 
gums  be  found,  this  track  of  inquiry  must  be  followed  up 
exhaustively  before  we  abandon  the  idea.  The  absence  of  all 
special  neurotic  history  in  a  patient's  family  should  increase 
our  suspicions'respecting  pains  of  this  character  that  continue 
with  an  obstinacy  which  makes  it  unhkely  they  are  due  to 
improper  food. 

'Pains  of  abdominal  irritation  are,  however,  without  doubt 
produced  in  some  cases  by  unsuspected  faults  of  diet,  and  may 
even  recur  in  such  a  quasi-periodic  manner  as  to  strongly  sug- 
gest the  fdea  of  neuralgia  in  the  lumbo-abdominal  nerve.  One 
special  variety  of  this  happens,  I  believe,  much  more  often 
than  is  thought.  A  patient  will  habitually  take  considerable 
quantities  of  some  article  of  food  which  he  does  not  readily 
digest,  but  which  is  not  at  all  acutely  irritant:  under  these 
circumstances  a  simple  accumulation  is  apt  to  take  place  in 
the  colon,  especially  at  the  top  of  the  ascending  colon,  the  top 
of  the  descending  colon,  or  just  above  the  sigmoid  flexure,  or 
else  in  the  csecum.  The  result  of  accumulation  in  the  last  of 
these  places  is  not  unfrequently  typhlitis  and  peritynhlitis, 
this  part  of  the  bowel  having  (for  some  reason}  a  s]Decial  ten- 
dency to  inflammation.  Deposits  in  the  other  localities  named 
are  rarely  the  cause  of  inflammation,  but  they  very  frequently 


DYSPEPTIC  HEADACHE.  331 

give  rise  to  violent  pain,  which  is  exceedingly  apt  to  be  taken 
for  the  pain  either  of  gall-stone,  of  renal  calculus,  or  else  of 
some  abdominal  neuralgia.  In  cases,  therefore,  where  there 
is  any  possibility  that  accumulation  is  the  cause  of  pain,  it  is 
highly  desirable  to  commence  with  a  dose  of  castor-oil  and 
laudanum,  followed  up,  if  needful,  by  the  administration  of  a 
large  warm-water  enema,  given  through  an  O'Beirne's  tube. 
The  most  violent  and  recurrent  attacks  of  pain  in  the  renal 
region,  the  flank,  the  abdomen,  or  the  groin,  will  sometimes 
be  instantly  cured  by  such  means,  sufficiently  proving  the 
non-neuralgic  character  of  the  complaint. 

I  have  elsewhere  explained  that  the  impaction  of  a  renal  or 
an  hepatic  calculus,  in  the  ureter  or  the  ductus  choledochus, 
may  set  up  a  true  neuralgia  in  persons  with  the  requisite  con- 
genital predisposition.  The  passage  of  renal  or  hepatic  calculi 
may  give  rise  to  symptoms  falsely  suggesting  neuralgia,  which 
require  just  to  be  mentioned  here.  But  there  is  no  need  to 
dwell  much  upon  the  diagnosis,  for  the  passage  of  renal  or 
hepatic  calculi  has  always  attendant  symptoms  and  features  of 
constitutional  history,  which  ought  to  preserve  the  physician 
from  mistake.  The  sensation  of  constriction,  of  nausea  and 
vomiting,  the  faintness  approaching  to  collapse,  the  persistent 
and  constantly  increasing  severity  of  the  pain  up  to  the 
moment  at  which  mechanical  relief  occurs,  to  say  nothing  of 
other  phenomena,  are  distinctive  to  the  skilled  observer,  and, 
when  taken  in  conjunction  with  the  history  of  past  attacks,  if 
any,  will  always  prevent  mistakes.  In  the  few  cases  which 
might  still  be  doubtful  it  will  be  well  to  try  the  the  efl'ect  of  a 
relaxing  dose  of  chloroform,  which,  in  the  case  of  calculus, 
will  often  put  an  end  to  the  paroxysm  at  once  and  finally. 


CHAPTER  XI. 

DYSPEPTIC  HEADACHE. 

A  final  word  or  two  must  be  given  to  the  distinction  between 
neuralgia  of  the  head  and  an  affection  so  utterly  different  that 
it  is  surprising  that  they  sho^ild  be  so  frequently  confounded. 
One  constantly  hears  medical  men  speak  of  "  sick  headache  " 
(migraine)  as  if  it  were  the  same  thing  as  headache  from  indi- 
gestion; and,  unfortunately,  they  often  treat  migraine  upon 
this  confused  and  erroneous  notion,  doing  no  little  mischief 
thereby. 

But,  although  migraine,  already  amply  described,  is  entirely 
independent  of  the  state  of  digestion,   and  its  stomach-phe- 


232  DYSPEPTIC   HEADACHE. 

noraena  are  purely  secondary  to  the  affection  of  the  fifth 
nerve,  there  is  a  kind  of  headache  really  dependent  on  imper- 
fect digestion.  Tiie  sufferers  from  tliese  headaches  are  dys- 
peptics whose  stomach  troubles  ai^e  the  result  of  chronic  gas- 
tric catarrhal  inflammation.  (In  the  acute  form  of  gastric 
catarrh  there  are  even  more  severe  headaches;  but  the  general 
gymptoms  of  the  disorder  are  too  marked  to  allow  us  to  mis- 
take the  case  for  neuralgia  complicated  with  secondaiy  stomach 
disturbance.)  The  patients  in  question  have  frequently  passed 
so  gradually  into  the  dyspeptic  condition  as  to  have  become 
accustomed  to  it,  and  inclined  to  forget  that  the  stomach  was 
the  organ  which  first  gave  them  annoyance.  The  headaches, 
which  occur  from  time  to  time,  are  either  frontal  or  (more  fre- 
quently) occipital  in  position,  and  they  are  usuallj^  quite  evenly 
bilateral;  still,  there  is  not  enough  uniformity  of  ditt'erence 
between  them  and  true  migraine,  in  this  respect,  to  enable  us 
to  establish  a  decided  diagnosis  upon  it.  This  much  may  be 
said,  however :  that  the  pain  is  rarely  or  never  seated  in  one 
parietal  region,  as  is  frequently  the  case  with  migraine  and 
with  clavus.  The  patient  suffers  very  strikingly,  in  almost 
every  case,  from  languor  and  a  feeling  of  inability  to  exert 
himself;  and  has  also  much  aching  pain  in  the  limbs,  and 
usually  a  pain  (sometimes  very  severe)  in  the  scapular  region. 
The  tongue  may  vary  a  good  deal  in  appearance,  especially  as 
regards  the  degree  of  general  redness;  but  it  always  has 
enlarged  papillae,  most  prominent  toward  the  tip,  and  more  or 
less  thick  furring  at  the  back,  and  reaching  forward,  in  some 
cases,  nearly  to  the  tip,  to  which  the  "  strawberry  "  aspect  is 
then  confined.  The  headache  is  frequently  joined  with  nau- 
sea, but  never  with  absolute  vomiting,  unless  the  stomach  has 
been  provoked  with  a  meal  that  gives  it  more  trouble  than 
usual.  The  desponding  frame  of  mind  which  this  kind  of 
dyspejptics  always  exhibit  distinguishes  them,  in  most  cases, 
quite  sufficiently  (together  with  the  unwholesome  coni]Dlexion, 
the  appearance  of  the  tongue,  and  the  great  complaints  of  gen- 
eral malaise  and  aching  and  feebleness  of  the  limbs)  from  the 
victims  of  migraine,  who  are  often  persons  of  bright  spirits 
and  lively  intelligence  in  the  intervals  of  their  attacks ;  but, 
above  all,  there  is  nothing  of  the  regular  and  characteristic 
sequence  of  events  which  distinguishes  the  attacks  of  migraine. 
The  attacks  are  not  periodic,  but  nearly  always  depend  on 
some  chance  dietary  indiscretion,  or  other  imprudence,  which 
has  visibly  aggravated  the  stomach  irritation .  And,  when  the 
pain  does  come  on,  it  has  no  uniform  tendency  to  go  on  inten- 
sifying for  some  hours  and  culminate  in  vomiting,  followed  by 
sleep,  after  which  the  patient  is  free.  On  the  contrary,  the 
digestive  disturbance  is' the  provocation,  and  the  pain  itself  is 
of  a  heavy  character,  with  a  sense  of  tension  or  fulness,  and  it 
does  not  go  on  intensifying  in  a  regular  inanner,  up  to  a  cli' 


DYSPEPTIC  HEADACHE.  233 

max,  but  hangs  about  in  a  dull,  tormenting  way,  and  fre- 
quently is  just  as  bad  after  sleep  as  it  was  before.  The  diag- 
nosis of  these  headaches  from  neuralgic  headache  is  not  really 
difficult;  it  only  requires  the  uso  of  a  fair  amount  of  caution 
in  observation .  It  would,  hoAvever,  be  exceedingly  advan- 
tageous that  the  word  "  sick-headache  "  should  be  dropped  alto- 
gether, and  that  migraine  should  always  be  called  by  that 
name  (or  '"megrim,"  if  you  will),  and  that  headaches  really 
proceeding  from  chronic  catarrhal  disease  of  the  stomach 
should  be  called  "dyspeptic"  headaches.  The  present  state  of 
nomenclature  does  much  to  perpetuate  a  confusion  of  ideas 
which  ought  not  to  exist  any  longer,  and  which  leads  to  much 
practical  mischief. 


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